HOSPITAL UNIVERSITRIO JLIO MULLER/SES

CENTRO DE INFORMAO SOBRE MEDICAMENTOS

CIM-HUJM
CLASSIFICAO Data solic. ___/___/___ Data resp. ___/___/___
01. Com paciente FI n ________/ 2009 Hora solic. _____:_____ Hora resp. _____:_____
02. Sem paciente
TEMPO GASTO: A. 0-5 minutos B. 6-30 minutos C. 31-59 minutos D. 1-5 horas E. 6-23 horas F. 1-3 dias G. Mais de 3 dias
DADOS DO SOLICITANTE

Nome: Tel: (65) Fax: ________________________

Endereo / E-mail: Municpio:

Clnica _____________________________________________________

SOLICITANTE:

01. Auxiliares e tcnicos enfernagem 04. Farmacutico 07. Paciente 99. Outros: ____________
02. Enfermeiro 05. Mdico 08. Residentes 00. No informado
03. Estudante 06. Nutricionista 09. Usurio
INSTITUIO:

01. HUJM 05. Hospital Regional 99. Outros

02. Hospital Regional Sorriso 06. Hospital privado 00. No informado
03. Hospital Regional Cceres 07. Indstria
04. Hospital Regional Rondonoplis 08. Universidade
SETOR

01. Ambulatrios 06. Clnica Peditrica 11. UTI NEO

02. Centro cirrgico 07. Farmcia 99. Outros____________________________
03. Clnica Cirrgica 08. Gerncia de risco 00. No informado
04. Clnica G.O 09. Pronto Atendimento
05. Clnica Mdica 10. UTI AD

DADOS DO PACIENTE: Idade: ___ anos. Sexo: ( )F ( )M Peso: Kg Altura: m

OBSERVAO: Somente se o solicitante for usurio: 01. Com prescrio mdica 02. Sem prescrio mdica

CLNICA DE INTERNAO: ________ ( Nmero do setor)

DOENAS:

D1:____________________________________ D2: ____________________________________ D3: ______________________________________

MEDICAMENTOS, ATC, INDICAES:

MED1: _______________________________ ATC1: _________________ Ind1: _____________________________________________________

MED2: _______________________________ ATC2: _________________ Ind2: _____________________________________________________

MED3: _______________________________ ATC3: _________________ Ind3: _____________________________________________________

MED4: _______________________________ ATC4: _________________ Ind4: _____________________________________________________

MED5: _______________________________ ATC5: _________________ Ind5: _____________________________________________________

PERGUNTA (CASO CLNICO): ____________________________________________________________________________

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HIPERSENSIBILIDADE: CONDIO ESPECIAL:
01. cido flico 07. Hialuronidase 01. Alcoolismo agudo 08. Lactao
02. AINES 08. Pirazolonas 02. Alcoolismo crnico 09. Menopausa
03. lcool benzlico 09. Salicilatos 03. Desnutrio 10. Paciente geritrico
04. Anestsicos gerais 10. Sulfonamidas 04. Gravidez ______________ 11. Paciente peditrico
05. Anfetaminas 99.Outros:_____________________ 05. Insuficincia cardaca 12. Pr-maturo __________________
06. Beta-lactmicos 06. Insuf. heptica 13. Tabagismo
07. Insuf. renal 99. Outros ______________________
TEMA SOLICITADO:
01. Administrao/modo de uso 07. Equivalncia teraputica 13. Farmacoterapia de eleio 19. Posologia / dose
02. Bibliografia 08. Estabilidade 14. Identificao 20. Reaes adversas
03. Compatibilidade 09. Farmacocintica 15. Indicaes de uso 21. Teratogenicidade
04. Conservao 10. Farmacodinmica 16. Interaes medicamentosas 22. Toxicologia
05. Contra-indicao 11. Farmacologia geral 17. Intercambialidade 99. Outros: ___________________
06. Disponibilidade 12. Farmacotcnica 18. Legislao
BIBLIOGRAFIA CONSULTADA:

01. BNF
02. British Pharmacopoeia
03. DEF
05. Dicionrio Mdico (Dorland`s)
06. Drugdex (MDX)
08. Drug Information (ASHP)
09. Drugs in Pregnancy Lactation
10. Drug interactions Facts (Tatro)
11. Drug Interactions (Stockley)
12. Drug treatment (Averys)
13. DTG (Korolkovas)
14. Facts and Comparisons
16. Farmacologia (Goodman)
18. Farmacologia (Penildon)
19. Farmacopia Brasileira
20. IDIS
21. Fitoterapia Vademecum
23. Handbook on Injectables (Trissel)
24. Herbal Medicines (Fetrow)
25. Index Nominum
26. Internet (ANVISA)
27. Internet outros ______________
28. Internet (FDA)
29. Manual Merck de Medicina
30. Martindale
31. Medicina Interna (Harrison)
32. Merck Index
35. Poisindex (MDX)
37. HIS PROD (PRVS)
38. Remington
39. Side Effects of Drugs (Meyler`s)
40. Textbook of ADR (Davie's)
41. Textbook of pediatrics (Nelson)
42. Tratado de fitomedicina (Alonso)
43. United States Pharmacopeia
44. USPDI vol.I
45. Australian Prescriber
46. Cochrane Library
47. Farmacologia Clnica (Lenita)
48. Internet (EMEA)
49. Banco de dados Cebrim/CFF
50. Clinical Evidence
99. Outros: ____________________

RESPOSTA: ______________________________________________________________________________________________
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ACOMPANHAMENTO: ____________________________________________________________________________________
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VIA DE RECEBIMENTO: [ ] 01. correio eletrnico

VIA DE RESPOSTA: [ ] 02. correio RECEBIMENTO: _______________________________________
03. fax
04. pessoalmente RESPOSTA: ______________________________________________
05. telefone
06. sistema