www.cspc.in   
 

 
 

 

 

 

 

 

 
The Official Website of Drug Information Centre (Chhattisgarh State Pharmacy Council)

DRUG INFORMATION REQUEST FORM

  *  Fields are Compulsory  
Date
Tuesday, February 19, 2019
Time 3:08:09 PM
Name of Enquirer
*   Phone No.
Mail ID
Address
 
*
Background/Qualification
 
*
The Enquirer's professional status
Physician
Surgeon Resident PG's Interns Nurse
Pharmacist
Community
Hospital Academic
Others
Patient Public
 
Mode of Request
Direct Access
During Ward Rounds Telephone Email Fax
Query from
India
Abroad
 
*
Details of Enquiry
Purpose of Enquiry
Update Knowledge
Better Patient Care Others
Answer needed
Immediately
With 30 minutes > 1 Hour More than a day
Patient Details
Age
Weight
Sex
Male
Female
 
Liver/ Renal Functions
Allergies
 
Current Medical Problems
Relevant Drug Therapy
 
 

Other Details

If Pragnent
First Trimester
Second Trimester
Third Trimester
If Breast Feeding Age of the Infant months