THERAPEUTIC DRUG MONITORING (TDM) REQUEST FORM

PATIENT PROFILE
Name : Ward / Unit : RN/IC :
Age : years Sex : Male / Female Race :
Weight (kg) : Height (cm) : DOA :
CLINICAL SUMMARY AND DIAGNOSIS

PATIENT CONDITION INDICATION FOR REQUEST

□ Oedema □ Smoker □ Dehydration □ Therapeutic Monitoring □ Poor Response
□ Dialysis □ Burn □ Liver Disease □ Suspected Toxicity □ Non Compliance
LATEST LAB RESULT CONCURRENT MEDICATION
Date Result
Blood Urea
Na₊ / K-
Creatinine
Albumin
Drug Analysis Date Time
Present Dose Regimen
Tick (V) where Appropriate Started Last Dose Pre-sampling Dose Given Post Given
Acetaminophen
Amikacin
Digoxin
Carbamazepin
Gentamicin
Phenobarbitone
Phenytoin
Salicylate
Theophylline
Valproic Acid
Vancomycin
Cyclosporin
Refer to TDM Serum Sample Guide
For injectable drug being analysed :
Infusion rate :
Duration of Infusion :
Doctor's Signature Name & Stamp Date
Drug Analysis Result Normal Therapeutic Range Pharmacokinetic Profiles Date Received:
K :
T ₁⁄₂ : Time Received:
Vd : Test Done :
Cr CL : Initials :
Pharmacist's Assessment and Recommendation:
Informed : ……………………………………….. on ……………………… at ………. am/pm Pharmacist's signature & Stamp
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