Optipharm.co.za

TREATMENT NAÏVE / NEW
(B) PRESCRIBING DOCTOR ASSESSMENT
PRINCIPLE MEMBER INFORMATION
Principal Member’s Initials
Principle Member’s First Name

Principal Member’s Surname

Identity Number

Medical Aid

Medical Aid Number
PATIENT INFORMATION

Patient Name

Patient Surname

Patient Identity Number
- - - Dependant Code

Contact Telephone Number

Allergies – Please tick the following if applicable:
Penicillin
Sulphonamides
Please specify other:
______________________________________________________________________________________________________
CLINICAL EXAMINATION
Is the treatment required as a prophylaxis - post exposure
Has the patient had:
Pancreatitis
Liver Disease
Kidney Disease
Elevated Uric Acid Level

CD 4 COUNT ___________________________ mm
VIRAL LOAD __________________________________ RNA Copies/ml

STD Screen __________________________________________________________________________________________________________________
TB Contacts YES / NO
WHO Staging _________________________________________________

TB Treatment, define: _________________________________________________________________________________________________________
Is patient pregnant? YES / NO
Date of last test: ______________________________________________________________________________________________________________

Is there any significant cervical and/or auxilliary lymphao anopathy?
Is there any abnormal finds on examination of skin?
If YES, please define: ______________________________________________________________________
Is oral candidissis present?
Is there evidence of recent memory loss or development delays (children)?
Are there any other findings on examination?
If YES, Please define: ______________________________________________________________________

PLEASE NOTE THAT THE EXAMINATION DETAILS ARE ESSENTIAL FOR REGISTRATION & AUTHORIZATION – KINDLY PROVIDE COPIES OF
PATHOLOGY REPORTS IF AVAILABLE.
HIV MEDICATION

NAME, STRENGTH & DOSAGE OF MEDICATION CURRENTLY PRESCRIBED
MONTHLY QUANTITY

PREVIOUS MEDICATION

MEDICATION
DURATION OF TREATMENT REASON
REASON CODES
DISCONTINUATION
RESISTANCE
B = SIDE EFFECTS

Other Medication used on a regular basis: ____________________________________________________________________________________
______________________________________________________________________________________________________________________________
Has member been hospitalized during the last 12 months YES / NO Date: ______________________________________________________

DOCTOR DETAILS
BHF PRACTICE NUMBER:
HPC REG NUMBER:
PRACTICE POSTAL ADDRESS:
PHYSICAL ADDRESS:

TELEPHONE NUMBER:
FAX NUMBER:


DOCTORS SIGNATURE: ______________________________________________________ DATE: ___________________________________________

CONDITIONS, UNDERTAKINGS & WARRANTIES

PATIENT CONFIDENTIALITY
All member/patient information disclosed by means of this application will be treated as confidential and wil not be revealed in
any form to any party other than the direct employees of Optipharm and the patients Medical Scheme, unless specific written
authorization/consent has been given to Optipharm by the patient.
IMPORTANT INFORMATION

OPTIPHARM
CUSTOMER CARE CALL CENTRE: 0 8 6 0 9 0 6 0 9 0

FAX NUMBER: 0 1 1 – 6 7 9 – 5 7 8 5

TELEPHONE NUMBER: 0 1 1 – 6 7 9 – 5 7 8 4
E-MAIL - GENERAL INQUIRIES/ MEDICINE RE-ORDERS
CLINICAL INQUIRIES: - WEBSITE:

Source: http://www.optipharm.co.za/documents/prescribing_doctor_assesment.pdf