• EXACT NAME OF THE CONDITION: Is this a lay term or the one used by the phsician? Is the patron sure of the spelling?
  
  
  
• WHAT PART OF THE BODY IS AFFECTED?
  
  
  
  
• AGE OF THE PATIENT?
  
  
• SEX OF THE PATIENT?
  
  
• TYPE OF INFORMATION NEEDED:
  

  Brief definition?_______________

  In-depth medical information?____________

  Written in layman's terms?_______________
  
  

• SPECIFIC INFORMATION NEEDED:
  

  Etiology (Cause)__________

  Diagnosis _____________

  Treatment _____________

  Signs or symptoms ___________

  Prognosis (Likely outcome)___________

  Specialists in the field __________

  Other (Explain)________
  
  

• PURPOSE: What prompts the person to ask? (Is this for a relative? For the patron? For the school?)
  
  
  
  
  
• SPECIFICALLY FOR DRUG INFORMATION REQUESTS:
  
  
• NAME OF DRUG: Is this a generic name or a trade name? Is the patron sure of the spelling?
  
  
  
• IS IT AN OVER-THE-COUNTER DRUG? (Available without a prescription?)
  
  
  
• WHAT SPECIFIC INFORMATION IS NEEDED: (For example, side effects, reason for prescribing?)
  
  
  
  
  
  
  
  
  

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This page was last updated on August 7, 2003.