BPHS Health Facilities Pharmaceutical Request Form

HFs Name and Type:

HFs ID:
Date of Request:
Name of HF: ‫د‬
‫د تیرو‬ ‫راتلوونکو‬
‫دریو‬ ‫اوسنی‬ ‫دریو‬
S/NO Description Unit Remarks
‫میاشتو‬ ‫میاشتو بیالنس‬
‫مصرف‬ ‫لپاره‬
1 Acetaminophen (Paracetamol), syrup 120mg/5ml
‫غوښتنه‬
2 Acetaminophen (Paracetamol), Tablet 100 mg

3 Acetaminophen (Paracetamol), tablet 500mg

4 Acetyl Salic Acid (Aspirin), tablet, 100mg

5 Acetyl Salicylic Acid (Aspirin), tablet 100mg

6 Acetyl Salicylic Acid (Aspirin), tablet, 500mg

Activated charcoal 500 mg per tablet, oral ingestion
7 tablet
Adrenaline , injection 1mg (as hydrochloride or
8 hydrogen tartrate) in 1-ml ampoule
Aluminium hydroxide 200+Magnesium hydroxide
200mg per 5 milliliter, in 200ml bottle, oral ingestion
9 suspension
Aluminum hydroxide 200mg + magnesium hydroxide
10 200mg, chewable tablet
11 Aminophylline, injection, 25mg/ml in 10-ml ampoule

12 Aminophylline, tablet 100mg

13 Amitriptylline, tablet, 25 mg (hydrochloride)

14 Amlodipine 5mg tablet

15 Amoxicillin 250mg disp.tablet

16 Amoxicillin 500mg disp.tablet

Amoxycillin, powder for oral suspension, 125mg
17 (anhydrous)/5ml syrup
Amoxycillin, powder for oral suspension, 250 mg/5m
18 syrup
Ampicillin, powder for injection 1g (as sodium salt) in
19 vial
Ampicillin, powder for injection 500mg (as sodium salt)
20 in vial
Anti–D immunoglobulin (human), injection, 250
21 microgram in single-dose vial
22 Artemether 20mg+Lumefantrine 120mg per tablet,
Artesunate 60mg+Sodium bicarbonate 5%+Sodium
23 chloride 0.9%injection vial
24 Atenolol, tablet, 100mg

25 Atenolol, tablet, 50mg

26 Atracurium 10 mg/ml inj 2.5ml ampule

27 Atropine inj 1mg/ml 1ml ampule

28 Atropine, tablet 1mg (sulfate)

29 Beclometasone oral inhaler 0.05mg/ds 200ds

Benzathine Benzyl Penicillin , powder for injection, 1,2
30 million IU in 5ml vial, i.m.
Benzathine Benzyl Penicillin , powder for injection, 2.4
31 million IU in 5ml vial, i.m.
32 Benzoic acid 6%+salicylic acid 3% ointement Tube-40g
33 Betamethasone 0.1% cream/TBE-15g
Betamethasone 0.1%+Neomycine 0.5% in 15g tube,
34 topical cream
35 Bupivacaine 5mg/ml inj 20ml ampule
Bupivacaine spinal heavy, spinal heavy 5mg/ml, 4ml,
36 Amp
37 Calcium carbonate 1500mg tabs

38 Calcium gluconate, injection 100mg/ml 10ml ampule

39 Carbamazepin, tablet 200mg

40 Ceftriaxone (restricted indication), vial 1 gram

41 Ceftriaxone (restricted indication), vial 500mg

42 Chloramphenicol 250mg capsule

43 Chloramphenicol pdr.inj 1g vial

44 Chlorhex.diglu.7.1% gel cord.c.TBE/20g

Chlorhexidine gluconate 1.5% +Cetrimide 15% solution

45
Chlorhexidine, solution, 5% (digluconate) for dilution-
46 1000ml BOT
Chlorhexidine, solution, 5% (digluconate) for dilution-
47 100ml BOT
Chlorine releasing comp., powder for solution, 1 gram
48 per liter
49 Chloroquine (base) 150 mg per tablet,

50 Chloroquine (base) 50 mg/5 ml, in 60 ml, oral syrup ,

51 Chlorpheniramine Maleate, injection 10mg/1ml

52 Chlorpheniramine Maleate, tablet 4mg

Ciprofloxacin (restricted indication), oral liquid
53 250mg/5ml
Ciprofloxacin (restricted indication), tablet 250mg (as
54 hydrochloride)
Ciprofloxacin (restricted indication), tablet 500mg (as
55 hydrochloride)
56 Cloxacillin , capsule 250mg (as sodium salt)

57 Cloxacillin , capsule 500mg (as sodium salt)

58 Cloxacillin , vial 500mg for injection

Compound Solution of Sodium Lactate (Ringer lactate),

Ringer lactate in 1000 milliliter, infusion solution
59
60 Condom, Male
Co-Trimoxazole (Sulfamethoxazole+Trimeth oprime),
61 suspension 200mg + 40mg/5ml
Co-Trimoxazole (Sulfamethoxazole+Trimeth oprime),
62 tablet 100mg + 20mg
Co-Trimoxazole (Sulfamethoxazole+Trimeth oprime),
63 tablet 400mg + 80mg
Depot medroxyprogesterone acetate for subcutaneous
64 (104 mg/0.65-ml) (DMPA-SC)
65 Diazepam 5mg tablet

66 Diazepam, injection 5mg/ml in 2ml ampoule

67 Diclofenac, injection 25mg per ml in 3 ml ampoule

68 Digoxin 0.25mg/ml inj. 2ml ampule

69 Digoxin, tablet 0.25mg

70 Dopamine 40mg/ml inj 5ml ampule

71 Doxycycline , capsule 100mg (hydrochloride)

72 Enoxaparin 6000IU/0.6ml Pre-filled Syringes

73 Epinephrine inj 1mg/ml 1ml ampule

 Ergometrine, injection 200 microgram (hydrogen
74 maleate)

Ergometrine, tablet 200 microgram (hydrogen maleate),

75
76 Erythro.pdr/oral sus 125mg/5ml/BOT-100ml
Erythromycin (Ethyl succinate), Suspension 100 mg per
77 ml 100 ml bottles
78 Erythromycin 250mg tablet
Ethinylestr/levonorgest. 0.03/ 0.15mg, 21+7placebo tab
79 cyc
80 Famotidine, tablet 40 mg,

81 Ferrous Sulfate, oral solution equivalent, 125mg/5ml

Ferrous Sulphat+Folic Acid , tablet, equivalent to 60 mg
82 iron + 400 microgram folic acid
83 Ferrous Sulphate, tablet, equivalent to 60 mg iron

84 Fluoxetine, capsule, 20mg

85 Folic Acid, tablet, 5 mg/tablet

86 Furosemide, injection, 10 mg/ml in 2-ml ampoule

87 Furosemide, tablet 40 mg,

88 Gentamicin inj 10mg/ml 2ml ampule

Gentamycine, injection 20mg (as sulfate)/2ml in 2ml
89 amp

Gentamycine, injection 40mg (as sulfate)/ml in 2ml amp

90
91 Glibenclamide , tablet, 5mg
Glucose 5%+Sodium chloride 0.9% in 1000ml bottle,
92 injection solution
Glucose 5%+Sodium chloride 0.9% in 500ml bottle,
93 injection solution
94 Glucose, injectable solution, 10%

95 Glucose, injectable solution, 5% isotonic

96 Glucose, injectable solution, 50% hypertonic

97 Glyceryl trinitrate 500mcg tablet

98 Haloperidol, tablet 5mg

99 Halothane sol.for inhal. 250ml bot

100 Heparin 5000IU/ml inj, 5ml vial

101 Human Tetanus Immunog 250IU/ml inj

Hydralazine, for injection, 20mg (hydrochloride) in
102 ampoule
103 Hydrochlorothiazid, tablet 25 mg
Hydrocortisone sodium succinate 100mg per vial,
104 injection vial
105 Hyoscine butylbr. 20mg/ml 1ml ampule

106 Ibuprofen, tablet 200mg

107 IInsulin 70/30 100IU/ml inj 10ml vl

108 Insulin injection (soluble) , 100 IU/ml in 10ml vial

109 Iodine Polyvidone, solution, 10%

110 Isosorbide Dinitrate, tablet, (sublingual), 10 mg

Ketamine, injection 50mg (as hydrochloride)/ml in 10ml
111 vial
112 Levonorgestrel 0.03mg tab, cycle

113 Levonorgestrel 0.75mg 2 tab bl

114 Levonorgestrel 150 mg per rods Implant

115 Lidocain inj 2% 50ml vial

 Lidocaine + Adrenaline, injection 1% (hydrochloride) +
116 epinephrine 1:200 000 in vial
Lidocaine + Adrenaline, injection 2% (hydrochloride) +
117 epinephrine 1:200 000 in vial
118 Lidocaine HCL, gel 2%

119 Lidocaine HCL, gel 4%

Lidocaine, dental cartridge, 2% (hydrochloride) +
120 epinephrine 1:80 000
121 Lindane, lotion, 1%
Magnesium Sulphate, injection 500mg/ml in 10ml
122 ampoule
Magnesium Sulphate, injection 500mg/ml in 2ml
123 ampoule
124 Magnesium trisilicate compd. Tablet

125 Mebendazole 500mg chew tablet

126 Mebendazole, chewable tablet 100mg

127 Medroxyprogesterone Acetate USP 150 mg/mL

128 Meglumine Antimoniate , 30% in 5 ml ampoule

129 Metformine, tablet, 500mg (hydrochloride)

130 Methyl dopa, tablet 250 mg

Methyl Rosanilinium Chloride (Gentian Violet) , aqueous
131 solution, 1%
132 Methylergometrine 0.125mg tablet
Metoclopramid , injection 5mg (hydrochloride)/ml in 2-
133 ml ampoule
134 Metoclopramid , tablet 10mg (hydrochloride),

135 Metronidazol , injection 500mg in 100ml vial

Metronidazol , oral suspension, 200mg (as
136 benzoate)/5ml
137 Metronidazol , tablet 250mg

138 Metronidazol , tablet 400mg

139 Miconazole 2% oral gel/TBE-20g

140 Miconazole 2% vag cream w 7 appl/TBE-45g

141 Misoprostol 200mcg tabs

Morphine, injection, 10mg (hydrochloride or sulfate) in
142 1ml ampoule
143 Multimicronutrients, capsule

144 Multivitamin & Mineral tablets

Naloxone, injection 400 microgram (Hydrochloride) in
145 1ml ampoule
146 Neostigmine 2.5mg/ml inj. 1ml ampoule

147 Neostigmine, Injection 0.5 mg per ml

148 Nifedipine 10mg IR Capsule

149 Nifedipine, tablet 10mg

150 Nitrofurantoin, tablet 100mg

151 Norgestrel 0.35 mg per tablet

152 Nystatin 500,000IU tablet

153 Nystatin oral sus 100,000IU/ml/BOT-30ml

154 Nystatin, 100 000 U vaginal tablet

155 Nystatin, drop 100 000 U/ml

156 Omeprazole 20mg capsules (e/c)

 Oral Rehydration Salt (for Glucose Electrolyte solution),
powder, 27,9 g/l sodium chloride (3.5 G/L), trisodium
citrate dihydrate (2.9 G/L), potassium chloride (1.5 G/L),
157 glucose (20 G/L); trisodium citrate

158 ORS low osm. 20.5g/1L

159 Oxytocin, injection, 10 IU in 1ml ampoule

160 Permethrin shampoo/solution 1%/BOT-100ml

161 Phenobarbital 100mg/ml inj 2ml

162 Phenobarbital, injection 200mg/ml ampoule

163 Phenobarbital, tablet 100mg

164 Phenobarbital, tablet 15mg

Phenoxy Methyl Penicillin (Penicillin V) powder for oral
165 suspension 250 mg/5 ml (as potassium salt)
Phenoxy Methyl Penicillin (Penicillin V), tablet 250mg
166 (as potassium salt)
Phenoxy Methyl Penicillin (Penicillin V), tablet 500mg
167 (as potassium salt)
168 Phytomenadione (Vit K), injection, 10mg/ml ampoule

169 Potassium Chl 15% inj 10ml ampoule

Potassium Chloride, 11.2 % solution in 20ml ampoule,
170 (equivalent to K+1.5mmol/ml, cl-1.5mmol/ml)
171 Povidone iodine sol 10%/BOT-500ml

172 Prednisolone 5mg tablet

173 Primaquine 7.5 mg per tablet,

174 Promethazine inj 25mg/ml 2ml ampoule

175 Propofol 10 mg/ml (1%) 20ml ampoule

176 Rabies Immunoglobulin, injection, 150 IU/ml in vial

Rabies vaccine (inactivated: prepared in cell culture),
Rabies antitoxin 150mg per milliliter, in 1ml , injection
177 vial
Retinol (Vit A), capsule 200 000 IU (as palmitate)
178 (110mg)
Salbutamol, inhalation (aerosol), 100 microgram (as
179 sulfate) per dose
Salbutamol, injection, 50 microgram (as sulfate)/ml in
180 5ml ampoule
Salbutamol, respirator solution for use in nebulizers,
181 5mg (as sulfate)/ml
182 Salbutamol, syrup, 2mg (as sulfate)/5ml

183 Salbutamol, tablet 4mg (as sulfate)

184 Silver Sulfadiaz. 1% cream 50g unsterile

185 Silver Sulfadiazine, cream 1%, in 500-gram container

186 Sod Hydrogen Carbonate 8.4% inj 10ml ampoule

Sodium Chloride, injectable solution, 0.9% isotonic
187 (equivalent to Na+154 mmol/l, Cl-154 mmol/l)
188 Sodium Stibogluconate, injection 100mg/ml ampoule
Suxamethonium (Succinyl Choline), injection, 50mg
189 (chloride)/ml in 2ml ampoule
Tetracaine, Tetracaine 0.5% in 15ml bottle, ophthalmic
190 drop
191 Tetracycline, eye ointment, 1% (hydrochloride)

192 Thiopental 500mg pdr.inj vial

193 Tramadol, injection 100 mg per 2 ml Ampoule

194 Tranexamic acid 100mg/ml 5 ml ampoules

195 Tranexamic acid 500mg tablet

196 Water for injection, 10ml ampoule

197 Water for injection, 5ml, ampoule

198 Zinc oxide ointment 10%/TBE-100g

199 Zinc Oxide, 20% in 20g tube, topical cream

200 Zinc, Zinc Dispersable Tablet 20mg strip of ten

201 Bag,urine,collecting,2000ml

202 Bandage,elastic,7.5cmx5m,roll

203 Cannula IV short 18G, ster, disp

204 Cannula IV short 20G, ster, disp

205 Cannula IV short 22G, ster, disp

206 Cannula IV short 24G, ster, disp

207 Catheter Urinary (folly), Size 16

208 Catheter Urinary (folly), Size 20

209 Catheter Urinary (folly), Size 22

210 Catheter Urinary (folly), Size 8

211 Catheter,Foley,CH10,ster,disp

212 Catheter,Foley,CH12,ster,disp

213 Catheter,Foley,CH14,ster,disp

214 Catheter,Foley,CH18,ster,disp

215 Chlorine, Powder (Kg)

216 Clamp,umbilical cord,ster,s.u.

217 Compress,gauze,10x10cm,n/ster

218 Compress,paraffin,10x10cm,ster

219 Cotton wool,500g,roll,non-ster

220 Developer powder for 10 lit (Pack)

221 Endotracheal tube 5mm (D), cuffed oral,

222 Face mask, venturi, adult, single use

223 Face mask, venturi, child, single use

224 Feeding tube Luer sterile ch10 40cm, 100

225 FirstResponse MalAgPf/Pv CardTest

226 Fixer powder for 10 lit (Pack)

227 Gauze,roll,90cmx100m,non-ster

228 Gloves sterile size, Size 7 (Pair)

229 Gloves,exam,nitrile,pwdfree,L

230 Gloves,surg,pwdfree,7.5,ster,s.u.,pair

231 Indicator tape, big size (Roll)

232 Infusion giving set,sterile,s.u.

233 Intrauterine Device Copper Coated

234 Mask,surgic,typeIIR,tiestrap,disp.pack50

235 Medical tape,2.5cmx5m,roll

236 Needle, spinal, 22G(0.7x90mm),ster

237 NeedleSpinal20G(0.9x90mm)Ster,disp

238 Plaster of paris bandage 10cmx2.7m,

239 Plaster of paris bandage 15cmx2.7m,

240 Plaster of paris bandage 20cmx2.7m,

241 Polyamide, Nylon suture, 12pc/Box

242 Resuscitator,hand-oper.,neonate,set

243 Safety box f.used syrgs/ndls 5lt/BOX-25

244 Scalpel blade,ster,disp,no.10

 245 Scalpel blade,ster,disp,no.11

246 Scalpel blade,ster,disp,no.22

247 Suction Catheter Size CH 12,

248 Suction Catheter Size CH 18,

249 Sut,abs,DEC2,need 3/8 18mm,round

250 Sut,abs,DEC2,need 3/8 26mm,tri

251 Sut,abs,DEC3,need 1/2 30mm,round

252 Sut,abs,DEC3,spool

253 Sut,abs,DEC4,need 1/2 30mm,round

254 Sut,abs,DEC4,need 3/8 50mm,round

255 Sut,nonabs,DEC1,need 1/2 13mm,rnd

256 Sut,nonabs,DEC2,need 3/8 18mm,tri

257 Sut,nonabs,DEC3,need 3/8 30mm,tri

258 Suture Vicryl (R/B) No.0 --90cm,

259 Syringe with needle 60ml

Syringe, autodestructable 1ml w/needle 22GX1'', For
260 Medroxyprgesterone
261 Syringe,disp,10ml,w/ndl,21G

262 Syringe,disp,20ml,ster

263 Syringe,disp,2ml,w/ndl,21G

264 Syringe,disp,5ml,w/ndl,21G

265 Thermometer, clinical, digital, no Li

266 Tongue depressor,wooden,disp/BOX-100

267 Triangular bandage

268 Tube nasogastric, CH 6, length 125cm, st

269 Tube,asp/feed,CH08,L125cm,ster,disp

270 Tube,asp/feed,CH12,L125cm,ster,disp

271 Tube,asp/feed,CH16,L125cm,ster,disp

272 Tube,endotrach,3.5,w/o cuff,ster,disp

273 Tube,endotrach,6.5,w/cuff,ster,disp

274 Tube,feeding,CH05,L40cm,ster,disp

275 Tube,feeding,CH08,L40cm,ster,disp

276 Tube,suction,CH08,L50cm,ster,disp

277 Tube,suction,CH10,L50cm,ster,disp

278 Tube,suction,CH14,L50cm,ster,disp

279 Tube,suction,CH16,L50cm,ster,disp
X- ray film, blue sensitive, interleaved, 18 x 24 cm, box
280 of 100
X- ray film, blue sensitive, interleaved, 24 x 30 cm, box
281 of 100
X- ray film, blue sensitive, interleaved, 30 x 40 cm, box
282 of 100
Requested by: Approved b
Position: Postition:
Signature: Signature:
Date: Date: