Patient:
_____________________________________________________ Date:
_____________
Allergies:
_____________________________________________________________________
Address: _____________________________________ City/State/Zip:
____________________
Home Phone: (___)______________________ Work Phone: (___)_________________________ |
|
| USED FOR |
FORMULA
STRENGTH
(Circle One) |
FREQUENCY |
| Bone Pain (NSAID) |
|
TID-QID |
| Bone Pain (NSAID) |
| Ibuprofen |
20% |
Piroxicam |
1% |
|
BID |
| Skeletal Muscle Spasms |
|
Q 4 h prn |
Active Herpes Zoster
or
Post Herpetic Neuralgia |
| Amitriptyline |
2% |
Ketoprofen |
10% |
| Tetricaine |
4% |
Deoxy-D-Glucose |
1% |
|
QID |
| Post Herpetic
Neuralgia |
| Bupivacaine |
1% |
Clonidine |
0.2% |
| Gabapentin |
6% |
Ketamine |
10% |
|
TID-QID |
| RSD |
| Guanethidine |
1% |
|
|
| Lidocaine |
1% |
2% |
5% |
|
Topical Spray 75ml
150ml |
|
Q 4-6 h |
| RSD |
| Amitriptyline |
1% |
2% |
|
| Ketoprofen |
5% |
10% |
|
| Carbamazepine |
2% |
Guanethidine |
1% |
| Lidocaine |
2% |
|
|
|
TID-QID |
| Neuropathies/Allodynia |
| Amitriptyline |
2% |
Baclofen |
2% |
|
TID-QID |
| Neuropathies |
| Amitriptyline |
2% |
Mexilitene |
2% |
|
TID-QID |
| Neuropathies |
|
TID-QID |
| Neuropathies |
| Tetracaine |
2% |
4% |
|
| Amitriptyline |
2% |
Amantadine |
2% |
|
TID-QID |
| Neuropathies |
| Gabapentin |
10% |
Ibuprofen |
5% |
| Lidocaine |
10% |
|
|
|
TID-QID |
| Neuropathies |
| Amitriptyline |
1% |
2% |
|
| Cyclobenzaprine |
1% |
2% |
|
| Tetracaine |
2% |
4% |
|
|
TID-QID |
| Neuropathies |
| Gabapentin |
3% |
6% |
10% |
| Clonidine |
0.1% |
0.2% |
0.3% |
| Tetracaine |
2% |
4% |
|
|
TID-QID |
| Neuropathies |
| Amitriptyline |
1% |
2% |
|
| Ketoprofen |
5% |
10% |
|
| Tetracaine |
2% |
4% |
|
|
TID-QID |
| Neuropathies |
| Amitriptyline |
1% |
7% |
|
| Ketoprofen |
5% |
10% |
|
| Gabapentin |
3% |
6% |
|
| Clonidine |
0.1% |
0.2% |
|
| Tetracaine |
2% |
4% |
|
|
TID-QID |
| Allodynia |
| Clonidine |
0.2% |
Gabapentin |
6% |
Ketamine |
10% |
|
TID |
| Your Own
Formulation |
|
|