Concomitant Measures / Medications
Form Completion Date
date
Course Number
integer
Course Day Number
(Enter the start date of the measure or medication.)
(Enter the stop date of the measure / medication.)
(In the case of agents, state the generic name of the medication administered, or, in the case of combinations such as trimethoprim / sulfamethoxazole, state the brand name i.e., Bactrim.)
text
(Note: Do not select a procedure if an agent name has been entered.)
(Enter the total daily dose of the agent as appropriate. In the case of combinations such as Bactrim, enter the total number of combination tablets taken daily. - - Note: If a procedure/measure, leave blank.)
(Select the total daily dose units of measurement. - Note: If a procedure/measure, leave blank.)
(Select the frequency of medication administration or measure under schedule.)
(Select the route given:)
(Select the reason the medication is being administered or why measure done. For example, if Bactrim is being given as a prophylactic, select "pneumocystis prophylaxis".)