Effect of Monazite Sands in Patients With Osteoarthritis of the Knee
Phase: NA
Conditions: Osteo Arthritis Knee
Sponsor: University Vila Velha

 
 
Documente date: May 3rd , 2019
Effect of Monazite Sands in Patients with Osteoarthritis of the Knee   
Ethical committee Protocol No: 3.160.891     
Pharmaceutical_log  
 

        
 
PHARMACEUTICAL LOG 
______________________________________________________________________________ 
 
 
 
                                                                    
 
                        
Page 1 of 3 
 
Study brief Title: 
Effects of Sand Treatment on Osteoarthritis   
Official Title: Effect of Monazite Sands in Patients with Osteoarthritis of the Knee   
Ethical committee Protocol No:  3.160.891    Unique Protocol ID:   T015-M02-2019AF002   
 
1. Do you use medications? 
  () Yes () No () DK / NR 
 
2. Do you always use medications according to prescription and medical advice? 
() Yes () No () DK / NR 
 
3. What medications do you use to treat osteoarthritis of the knee? 
_______________________________________________________________________ 
() DK 
 
4. Do you feel relief or improvement with the use of medications? 
() Yes () No () DK / NR 
 
5. Where is your medicine stored? In what room of the house? You can choose more than one answer option: 
() Bathroom () Kitchen () Bedroom 
() Room / Cup () DK / NR 
(     ) Others: _________________________________________________ 
 
6. Was any of the drugs listed below used? 
Drug 
Posology 
Today 
Yestarday 
Two days ago 
Thre days ago 
Indication1 
(    ) Paracetamol 
 
 
 
 
 
 
(    ) Dipirona 
 
 
 
 
 
 
(    ) Ibuprofen 
 
 
 
 
 
 
(    ) Codeína 
 
 
 
 
 
 
(    ) Tramadol 
 
 
 
 
 
 
Others 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. Legend Indication: (1) Physician / Dentist / Nurse (by prescription); (2) Self-indication (Self-medication); (3) 
Pharmacist / Clerk; (4) Family; (5) Relatives / Friends. 
 
7. After using any of the medications listed in the previous question for pain management (painkillers, 
anti-inflammatories or opioids) how did you feel? 
___________________________________________________________________________ 
8. Of the medicines used for pain treatment in the past few days, you have: 
() Decreased frequency of use. () Increased frequency of use. 
() Made use continuously. () DK / NR. 
9. In general, when you do not feel well do you use medicines on your own or indicated by a friend, 
relative, among others (self-medication)? () Yes () No () DK / NR Which: _____________________ 
 

10. At present, which drugs do you use that have been prescribed by your doctor? 
OBS: Observe the last prescriptions of the patient. 
 
11. What is your educational level? () DK / NR __________________________ 
12. You could report your family income () Yes, what amount? ___________ () No () DK / NR 
13. How many people live with you? ______ people 
 
 
 
 
Signature of the Principal Investigator: 
 
 
 
 
 
 
     
 
Date: 
 
 
Drug 
( active principle and 
trade name if any) 
Drug details 
 
Brand 
Generic 
Similar 
Posology  
Who 
prescribed¿ 
Do you know 
what you are 
taking for this 
medicine? If 
yes, for what?  
How do you 
use this 
medicine? 
(See if use is 
incorrect)  
Since when 
do you use 
this 
medication? 
(days / 
months / 
years)) 
After you 
started taking 
this medicine, 
did you feel 
any different 
reaction in 
the body? 
(any adverse 
reactions?) If 
yes, which 
one? 
 
Did you get 
this 
medication at 
the SUS 
pharmacy or 
at a private 
pharmacy? 
Specify the 
location and 
how (free / 
paid) the 
patient 
purchased the 
medicine 
1 - 
 
 
 
 
 
 
 
 
2 - 
 
 
 
 
 
 
 
 
3 - 
 
 
 
 
 
 
 
 
4 -  
 
 
 
 
 
 
 
 
5 -