15.3.5. Pharmacy Client Data Collection Form Retail Pharmacy name: ___________________________ Date: ____________ Data collected from: prescriptions / dispensing register / computer registry / bills Please circle Age Px No. AB INJ VIT No. No. Drug names (preferably generic names but brand names Cost per # Diagnosis No. items No. generics TRM if generic names unknown) Px (yrs) Y/N (Y/N) (Y/N) (Y/N) on dispensed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
15.3.5. Pharmacy Client Data Collection Form Retail Pharmacy name: ___________________________ Date: ____________ Data collected from: prescriptions / dispensing register / computer registry / bills Please circle # Diagnosis Age (yrs) Px Y/N No. No. generics No. TRM AB (Y/N) INJ (Y/N) VIT (Y/N) No. items on No. dispensed Drug names (preferably generic names but brand names if generic names unknown) Cost per Px 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
tool_7_medicines_in_health_care_delivery_10mar2016.docx