Inventory from and illness recall form PDF

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Download Inventory from and illness recall form PDF

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Household Medicine/Drug/ Vitamins/ Herbs etc Inventory (Please note should modify this form if using at a store/ market and note Informants age and position in store-- no real names needed) Student Name: Date: Medicine Name

Manufacturer

Contents (Generic name)

Expiry date

Used for what?

Where Obtained?

Whose Advice? /Price?

Maxolon

Inova

Metoclopramide

06/2021

Nausea

Pharmacy

Dr T, $7.50

Tmaze

Alpha pharm

Temazepam

08/2020

Sleeping

Pharmacy

Dr T, $20.56

Reapton 5/5

Servier

Perindopril Arginine & Amlodipine

02/2022

Blood Pressure

Pharmacy

Dr T, $7.39

Dymista

Mylan

Azelastine & Fluticasone

10/2020

Allergy

Pharmacy

Dr T, $48.39

Activated Charcoal Tablets

Charcotabs

Charcoal

06/2021

Flatulence

Grandmother

Grandmother, price n/a

Vitamin D

Swisse

Vitamin D3

11/2020

Vitamin Replacement

Woolworths

Dr T, $11

Doxycycline Sandoz

Sandoz

Doxycycline

04/2020

Acne Treatment

Chemist

Dr T, $5.40

Panadol

Panadol

Paracetamol

06/2021

Reliefs from Pain and fever

Woolworths

n/a, $5.50

Nurofen

Nurofen

Ibuprofen

03/2020

Reduce inflammation and relief from pain

Woolworths

n/a, $5.90

Aspirin

Aspro

acetylsalicylic acid

05/2022

Headache, sore throat

Coles

n/a. $5.00

Betadine Throat Gargle

Betadine

Povidone-Iodine

11/2019

kills bacteria that may cause a sore throat

Woolworths

$13.50

Voltaren Rapid 12.5

Voltaren

Diclofenac

11/2020

anti-inflammatory

Chemist

$5.99

Illness Form (Complete one for each episode/ respondent) Pseudonym of ill person: Dr T

Illness suffered (use respondents’ own words): Hypertension

Date: November 2018 – Current Interviewer: Anastasia Age patient: 57 Gender: Female 1st treatment tablets Reaptan

2nd treatment Exercise

3rd treatment Low Salt Diet

Effect of treatment according to respondent

Lowers blood pressure

Lowers blood pressure

Helps kidney function

For pharmaceuticals give contents as specified on packet

Perindopril Arginine & Amlodipine

Dosage/ form (ie tablet, capsule, syrup, tea etc)

1 tablet

5 times a week

At meal time

Duration of treatment (no. of days, doses/day, give start date in brackets)

For life

For life

For life

Who advised?

Cardiologist – Dr N

Themselves

Themselves

Where obtained?

Chemist

Cost per unit (specify ml per bottle, number of tablets etc)

$7.39

Name of treatment

$35 fortnight gym membership

Questions for Illness Interview: For all respondents: Ask age, preferred gender. Have you been ill during the past week? Yes What did you suffer from? (write down respondents own terms used) nausea Did you take any treatment? (Specify the names of home or herbal remedies or any pharmaceuticals given) Maxolon, drank water What was the effect of the treatment? (Probe for all treatments given) stopped nausea, tiredness For any pharmaceuticals ask: Can I see the package of the medicine? (Copy details of contents if given on the package) Ask about dosage/duration: When did you start taking the medicine? How many doses in a day and for how many days did you treat the problem? 1 tablet, 1 day For all treatments ask: Who advised you to take the treatment? Myself Where did you get the medicine? Chemist How much did it cost? $7.39

Illness Form (Complete one for each episode/ respondent) Pseudonym of ill person: C

Illness suffered (use respondents own words): Cold

Date: 20/09/19 – 23/09/19 Interviewer: Anastasia Age patient: 17 Gender: Male Name of treatment

1st treatment Panadol

2nd treatment Betadine

Effect of treatment according to respondent

Make sickness go away, and feel better after

Kill bacteria in throat so don’t hurt as much

For pharmaceuticals give contents as specified on packet

Paracetamol

Povidone-iodine

Dosage/ form (ie tablet, capsule, syrup, tea etc)

2 tablets

Syrup, 1 cup provided with packaging

Duration of treatment (no. of days, doses/day, give start date in brackets)

3 days

Once only

Who advised?

Themselves

Themselves

Where obtained?

Woolworths

Woolworths

Cost per unit (specify ml per bottle, number of tablets etc)

$4

$9.5

3rd treatment

Questions for Illness Interview: For all respondents: Ask age, preferred gender.

Have you been ill during the past week? No What did you suffer from? (write down respondents own terms used) nothing Did you take any treatment? (Specify the names of home or herbal remedies or any pharmaceuticals given) no What was the effect of the treatment? (Probe for all treatments given) no For any pharmaceuticals ask: Can I see the package of the medicine? (Copy details of contents if given on the package) Ask about dosage/duration: When did you start taking the medicine? How many doses in a day and for how many days did you treat the problem? For all treatments ask: Who advised you to take the treatment? Where did you get the medicine? How much did it cost?

Illness Form (Complete one for each episode/ respondent) Pseudonym of ill person: L

Illness suffered (use respondents’ own words): Backpain from scuba diving

Date: 28/09/19 Interviewer: Anastasia Age patient: 20 Gender: Male 1st treatment Voltaren

2nd treatment Massage pillow

Effect of treatment according to respondent

Stops my back hurting

Help to take pain and give relief to my back

For pharmaceuticals give contents as specified on packet

Diclofenac

Dosage/ form (ie tablet, capsule, syrup, tea etc)

2 tablets

Duration of treatment (no. of days, doses/day, give start date in brackets)

Every 4 hours, 1 day

Once when they got home

Who advised?

Themselves

Themselves

Where obtained?

Pharmacist

Cost per unit (specify ml per bottle, number of tablets etc)

$14.50

Name of treatment

n/a

3rd treatment

Questions for Illness Interview: For all respondents: Ask age, preferred gender.

Have you been ill during the past week? What did you suffer from? (write down respondents own terms used) Did you take any treatment? (Specify the names of home or herbal remedies or any pharmaceuticals given) What was the effect of the treatment? (Probe for all treatments given) For any pharmaceuticals ask: Can I see the package of the medicine? (Copy details of contents if given on the package) Ask about dosage/duration: When did you start taking the medicine? How many doses in a day and for how many days did you treat the problem? For all treatments ask: Who advised you to take the treatment? Where did you get the medicine? How much did it cost?...