PHARMACOLOGICAL MONITORING


PATIENT DATA

Name:
Date of Birth:
Sex:  
Height (cm):
Weight (kg):
Medical Diagnostic:

DETAILS OF DISCOMFORT

START OF DISCOMFORT:
DOES THE DISCOMFORT CONTINUED?  
DETAILS OF DISCOMFORT:
RESULTS OF DISCOMFORT:
DRUG FORMULA:
TRADE NAME:
Lot number:
Expiration date:
Amount consumed:
Units:
Frecuency:
Administration route:
REASON OF MEDICATION
Start date
Are you currently using the drug?  
Have you stopped using the drug?  
Did the discomfort disappear when you stopped using the drug?  
Have you used again the drug?  
Have you presented the discomfort after using again the drug?  
Have you used any medication to eliminate the discomfort?  

DRUG ADMINISTERED WITH THAT CAUSED THE DISCOMFORT

Drug Dose Start date
End date Medical diagnosis

OTHER DISEASES, SURGERIES, ALLERGIES, PREGNANCIES.

Other Diseases, Allergies, Surgeries, Pregnancies:

PATIENT PROFILE (FOR PURPOSES OF CONTINUING RESEARCH)

Address:
Phone:    
Email:
* Required information