Age* No. No. TRM AB INJ VIT No. items No. items Drug (preferably generic names but brand names if Cost per # Diagnosis (yrs) items generics (Y/N) (Y/N) (Y/N) (Y/N) on dispensed generic names unknown) prescription 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Totals Average % of % of % of % of % of % of total total % of % total items items items items cases cases cases *If <1 year indicate as follows: 3 months = 3/12, 5 months = 5/12, etc.; TRM=Traditional Medicine; AB=Antibiotic; INJ=Injection; VIT=Vitamin
# Diagnosis Age* (yrs) No. items No. generics TRM (Y/N) AB (Y/N) INJ (Y/N) VIT (Y/N) No. items on No. items dispensed Drug (preferably generic names but brand names if generic names unknown) Cost per prescription 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Totals Average % % of items % of total items % of cases % of cases % of total cases % of items % of total items *If <1 year indicate as follows: 3 months = 3/12, 5 months = 5/12, etc.; TRM=Traditional Medicine; AB=Antibiotic; INJ=Injection; VIT=Vitamin