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    CP Log Book Forms

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    mrcopy xerox

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    © All Rights Reserved
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    CP Log Book Forms

    Uploaded by

    mrcopy xerox
    50 views4 pages

    Original Title

    CP LOG BOOK FORMS

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    50 views4 pages

    CP Log Book Forms

    Uploaded by

    mrcopy xerox

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    DEPARTMENT Or PUARMACY PRACTICE

    ANWARUL-ULOOM COLLEGE OF PHARMACY


    New mallepally, Hyderabad-50000
    LABDATA INVESTIGATION FORM
    PATIENT NAME: IPNO: DOA:
    AGE: WEIGHT: SEX UNIT: DOD:
    Complaints On Admission:

    Patient Ristory F'amily History:


    Medical Allergies:
    Medication: Drugs:
    Social History:

    Physical Examination:
    General: CVS: RS: CNS: Others:
    Provisional Diagnosis:

    Routine biochemical investigation:


    BUN: (5-25 mg/dl): Billi.: T(O0.21-2mg/dl):
    Haematology:
    Hb: 1(14-18 gm%)
    S.Cr.: (0. 7-1.4 mg/dl): D(0.10-0.14mg/dl): M(12-16gm%)
    Na: (137-145 mmol/L):
    SGOT(5-40 IU/L) F (10-14 gm%)
    Ca: (8.1-10.44 mg/d): SGPT(8-40 IU/L):
    Cr:(123-135 mmol/L): T.Protein(6-8gm/dl): RBC.: M (4.2-6.5*10
    K:(3.6-5.0 mmol/L) Alkaline Phosphatase F(3.7-5.610)
    (38-126 IU/L)
    CKMB (0-10 IU/L):
    FBS(70-110mg/dl): Reticulocyte:
    T.Chol.(130-200mg/dl): RBS (70-120mg/dl): WBC: (4-11*10*)
    TGs (40-70mg/d):
    LDL (130-159 mg/dl): PPBS (70-140mg/dl): cells/cumm
    VLDL (25-40mg/dl): HbA1C (4.2-6.2):
    CHO/HDL ratio (1-5mg/dl):

    Urine Analysis: DLC:


    Color: Ep.cells Neutrophils (40-70% Platlets: (1.5-4.5lac/m)
    Albumin: Pus cells: Lymphocytes (20-40%) ESR: M (0-20mm/hr)
    Sugar: Others: F (0-30mm/hr)
    Casts: Bosinophils (1-6%) PCV: M (39-54%)
    WBC:
    F(3448%)
    RBC:
    Monocytes (2-10%). MCV: (75-95 cu.mnc)
    Basophils (0-4%) MCH: (26-32 pg/cells)_|
    MCHC: (30-35gm%)|
    Other Lab data:
    Drugs Treaiment Chart

    Current Drugs Dose Route Freq 2 1 4 [5|6 7 | 9 10 Days

    Lab Data interpretation:

    Final Diagnosis:

    Discharge Medication: Written By:

    Follow Up: Evaluated By:


    ANWARULUROOM COLLEGE.OF PHARMACY
    Department of Pharnacy Practice, Hyderabad.

    Mcdieation llistory Interview Form

    Patient's Name: M/ DOB: M/F:

    Consultant: Pregnancy: Ward/l.P No:

    Admission Date: Breast Feeding: MHI Date:


    PRESCRIBED MEDICATION - What medicines are you having at the moment?

    Other drugs prescribed previously (with dates if possible): Immunisation History

    NON-PRESCRIBED MEDICATION - is any druug that was brought from a shop (pharmacy, health

    food store and supermarket) without a prescription?


    a) Currently being used:

    b) Used previously (with dates if possible):

    SOCIAL HABITS -

    (Quantity used & since how many years)


    a) Smolking
    b). Alcohol:
    c). Ilicitdrugs:
    RESPONSE TO DRUG THERAPY
    a) Do y0u think your previous medication benelited you?

    If yes, which ones and how?

    f no, why?
    Do any of the th1gs you buy withoul a preseription hely you?

    i fyes. how and nhich ones?

    What haVe you bcen iold albout your medicines and by wlhom7

    SIDE-FTECTS ALLERGIES

    a) Are you suffering anyside effects now? a) Do you any allergies?


    Medication:
    Ifyes, what side effects?

    b) liave you suffcred any side effecis with previous drug treatments? Food:

    if yes, what side effccts and with wlhich medicines?

    Compliance
    a) How do you remember to take your medication?

    b) What do you do when you miss a dose?

    what medicines would youusually take for


    a) A headache:

    b) Aches-Pains/Cold:

    c) Fever:

    Do you know how to take your regular medicines? If yes, who told you?

    If 'No',then who would you ask?


    a) Doctor's Assistant: e) Doctor
    b) Pharmacis1/chemist: ) Other, please specify:
    c) Relative or Friend: g) No-one:

    d) Nurse:

    ANY OTHER PROBLEMS WITH DRUG THERAPY?

    COMMENTS/RECOMMENDATIONS:

    Signature af Student Signature of Stalf

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