WO2005087506A1

WO2005087506A1 - Prescription pad

Info

Publication number: WO2005087506A1
Application number: PCT/US2005/008581
Authority: WO
Inventors: Patricia S. Walker
Original assignee: Allergan, Inc.
Priority date: 2004-03-10
Filing date: 2005-03-08
Publication date: 2005-09-22

Abstract

A prescription form comprises a sheet or a plurality of sheets superimposed upon one another and adhesively secured together along one side thereof, the sheet(s) having a first zone for entry of information identifying a patient for whom a pharmaceutical product is being prescribed, a second zone for entry of risk management assessment of the patient, a third zone for entry pharmaceutical product and dosing instructions, and a fourth zone for entry of a signature of a prescribing medical practitioner.

Description

PRESCRIPTION PAD

Figure 1 shows a prescription form in accordance with the present invention which includes a sheet having a first zone for entry information identifying a patient for whom a pharmaceutical product is being prescribed, a second zone for entry of risk management assessment of the patient, a third zone for entry of the pharmaceutical product dosing instructions and a fourth zone for entry of a signature of a prescribing medical practitioner.

More particularly, the second zone includes indicia setting forth a criteria for use management assessment which may include questions regarding patient life status and pregnancy state of the patient.

In addition, the second zone may further include indicia for enabling recordation of confirmed practitioner-patient discussions of risk management.

Figure 2 is an alternative embodiment, of the present invention which includes a second sheet identical to the first sheet shown in Figure 1 disposed thereunder along with a transfer medium, shown in dashed line, for transferring impressions from the first sheet to the second sheet.

Figure 3 is an embodiment of the present invention shown under that shown in Figure 2 but including the plurality of multi form sheets superimposed upon one another with each multi-form unit including identical sheets with each sheet having the zones set forth hereinabove in connection with the embodiment shown in Figure 1.

Both the embodiment shown in Figure 2 and 3 may have adhesive bonding along one side of the form to produce a pad structure .

Figure 4 shows yet another embodiment of the present invention which includes the form hereinabove noted and described in Figures 1-3 and further including an instruction sheet having indicia regarding questions to be asked by the practitioner of the patient. The instruction sheet is preferably separable from a remainder of the form as indicated by a dash line in Figure 4 representing perforations or the like. Although there has been hereinabove described a specific prescription pad in accordance with the present invention for the purpose of illustrating the manner in which the invention may be used to advantage, it should be appreciated that the invention is not limited thereto. That is, the present invention may suitably comprise, consist of, or consist essentially of the recited elements. Further, the invention illustratively disclosed herein suitably may be practiced in the absence of any element which is not specifically disclosed herein. Accordingly, any and all modifications, variations or equivalent arrangements which may occur to those skilled in the art, should be considered to be within the scope of the present invention as defined in the appended claims.

Claims

WHAT IS CLAIMED IS:

1. A prescription form comprising: a sheet having a{ first zone for entry of information identifying a patient for whom a pharmaceutical product is being prescribed, a second zone for entry of risk management assessment of the patient, a third zone for entry of the pharmaceutical product and dosing instructions, and a fourth zone for entry of a signature of a prescribing medical practitioner .

2. The prescription form according to claim 1 wherein said second zone includes indicia setting forth a criteria for risk management assessment.

3. The prescription form according to claim 2 wherein said criteria includes questions regarding the patients life status.

4. The prescription form according to claim 3 wherein the questions include the sex and pregnancy status of the patient.

5. The prescription form according to claim 4 said second zone further includes indicia for enabling recordation of confirmed practitioner-patient discussions of risk management.

6. The prescription form according to any one of the claims 1-5 further comprises a second sheet, identical to said first sheet and disposed thereunder and a transfer medium for transferring impressions from said first sheet to said second sheet.

7. The prescription form according to any one of claims 1-5 further including an instruction sheet having indicia regarding questions to be asked by the practitioner of the patient.

8. A prescription form comprising: a plurality of sheets superimposed upon one another and adhesively secured together along one side thereof, each sheet having a first zone for entry of information identifying a patient for whom a pharmaceutical product is being prescribed, a second zone for entry of risk management assessment of the patient, a third zone for entry of the pharmaceutical product and dosing instructions, and a fourth zone for entry of a signature of a prescribing medical practitioner .

9. The prescription form according to claim 8 wherein said second zone includes indicia setting forth a criteria for risk management assessment.

10. The prescription form according to claim 9 wherein said criteria includes questions regarding the patients life status.

11. The prescription form according to claim 10 wherein the questions include the sex and pregnancy status of the patient,

12. The prescription form according to claim 11 said second zone further includes indicia for enabling recordation of confirmed practitioner-patient discussions of risk management.

13. The prescription form according to any one of claims 8-12 further including an instruction sheet having indicia regarding questions to be asked by the practitioner of the patient.

14. A prescription form comprising: a plurality of multi-form units superimposed upon one another, each multi-form unit including identical sheets each sheet having a first zone for entry of information identifying a patient for whom a pharmaceutical product is being prescribed, a second zone for entry of risk management assessment of the patient, a third zone for entry of the pharmaceutical product and dosing instructions, and a fourth zone for entry of a signature of a prescribing medical practitioner; and a transfer medium for transferring impressions between identical sheets of a multi-form unit.

15. The prescription form according to claim 14 wherein said second zone includes indicia setting forth a criteria for risk management assessment.

16. The prescription form according to claim 15 wherein said criteria includes questions regarding the patients life status.

17. The prescription form according to claim 16 wherein the questions include the sex and pregnancy status of the patient.

18. The prescription form according to claim 17 said second zone further includes indicia for enabling recordation of confirmed practitioner-patient discussions of risk management.

19. The prescription form according to any one of claims 14-18 further including an instruction sheet having indicia regarding questions to be asked by the practitioner of the patient.