Data Collection Form

AMP 2 Form

Complete this form for all drugs prescribed to each patient. This information must also be entered online at:

1.Your Unique Identifier Number:
Patient identifier:

Age of patient: 12 or under [ ] 13 or over [ ]

2.Diagnosis

Please tick all that apply / Yes
ANUG
Angular cheilitis
Apical abscess - Acute
Apical abscess - Acute with systemic involvement
Apical periodontitis – Acute
Apical periodontitis – Chronic
Candida/fungal infection
Dry socket
Periocoronitis
Periodontal abscess
Pulpitis – Reversible
Pulpitis – Irreversible
Recurrent Aphthous Stomatitis (Oral Ulceration)
Sinusitis
Viral infection
Other:

3.Reasons for prescribing (signs and symptoms):

Please tick all that apply / Yes
Spreading infection – Cellulitis
Spreading infection – Lymphadenopathy
Swelling – Localised
Swelling – Diffuse
Systemic involvement - (fever, malaise)
Pain
Mucosal ulceration
Previous local measures failed
Prophylaxis against bacterial endocarditis
Other:

4.Interventions made in addition to prescribing.

Please tick all that apply / Yes
None
Extraction
Establish drainage by incision
Establish drainage by opening tooth
Dress tooth - no pulp Tx
Dress tooth - with pulp Tx
Advise local measures
Other:

5. Additional observations.

Please tick all that apply / Yes
None
Previous local measures failed
Patient unable to co-operate
Patient declined local measures
Patient demand
Relevant medical history
Allergic to certain antimicrobials
Time pressures

6. What medication was prescribed: (there will be chance to input other medications later if required)

Medication / √ / 7. Dosage (mg): / √ / 8. Frequency (times per day): / √ / 9. Duration (number of days): / √
Aciclovir (all types) / 7. / 1 / 1
Amoxicillin (all types) / 50 / 2 / 2
Ampicillin (all types) / 62.5 / 3 / 3
Azithromycin / 75 / 4 / 4
Cefalexin (all types) / 125 / 5 / 5
Cefradine / 150 / 6 / 6
Clarithromycin (all types) / 200 / 7
Clindamycin (aka Dalacin C) / 250 / > 7
Co-amoxiclav (all types) / 400
Doxycycline (all types) / 500
Erythromycin (all types) / 800
Fluconazole (all types) / 3g
Metronidazole (all types) / Other
Miconazole (all types)
Nystatin oral suspension
Oxytetracycline
Penciclovir cream
Phenoxymethylpenicillin (all types)
Sodium Fusidate ointment
Tetracycline
Other:

7.Were any other medications prescribed to this patient?

No/Yes (please provide more information)

11. Medication / √ / 12. Dosage (mg): / √ / 13. Frequency (times per day): / √ / 14. Duration (number of days): / √
Aciclovir (all types) / 7. / 1 / 1
Amoxicillin (all types) / 50 / 2 / 2
Ampicillin (all types) / 62.5 / 3 / 3
Azithromycin / 75 / 4 / 4
Cefalexin (all types) / 125 / 5 / 5
Cefradine / 150 / 6 / 6
Clarithromycin (all types) / 200 / 7
Clindamycin (aka Dalacin C) / 250 / > 7
Co-amoxiclav (all types) / 400
Doxycycline (all types) / 500
Erythromycin (all types) / 800
Fluconazole (all types) / 3g
Metronidazole (all types) / Other
Miconazole (all types)
Nystatin oral suspension
Oxytetracycline
Penciclovir cream
Phenoxymethylpenicillin (all types)
Sodium Fusidate ointment
Tetracycline
Other:

8. Were any other medications prescribed to this patient?

No/Yes (please provide more information)

16. Medication / √ / 17. Dosage(mg): / √ / 18. Frequency (times per day): / √ / 19. Duration (number of days): / √
Aciclovir (all types) / 7. / 1 / 1
Amoxicillin (all types) / 50 / 2 / 2
Ampicillin (all types) / 62.5 / 3 / 3
Azithromycin / 75 / 4 / 4
Cefalexin (all types) / 125 / 5 / 5
Cefradine / 150 / 6 / 6
Clarithromycin (all types) / 200 / 7
Clindamycin (aka Dalacin C) / 250 / > 7
Co-amoxiclav (all types) / 400
Doxycycline (all types) / 500
Erythromycin (all types) / 800
Fluconazole (all types) / 3g
Metronidazole (all types) / Other
Miconazole (all types)
Nystatin oral suspension
Oxytetracycline
Penciclovir cream
Phenoxymethylpenicillin (all types)
Sodium Fusidate ointment
Tetracycline
Other:

Please retain this copy for your records after you have entered the information online.