Medication Check List
   
   
   
 

MEDICATION CHECK CHECKLIST

 

Name_____________________________Date__________________Date of Birth__________________

 

 

Current medications                     Dosage                          Side effects

 

1

2

3

4

5

6

 

 

Have you had any medical problems or new medications prescribed since our last appointment?  If so, please explain.

 

 

 

Have you experienced any of the following SINCE YOUR LAST APPOINTMENT?  Please circle if you have.

 

Rash

Dizziness

Headache ___How often?____________                  Migraine__________

Dry mouth

Palpitations

Nausea

Diarrhea or loose bowels

Elevated blood pressure

Constipation

Tics

Vertigo

Ringing in the ears

Difficulties urinating

Inability to fall asleep                   How long do you lie awake?________

Waking in the night                     How many hours do you sleep before waking?_________

                                                How long does it take for you to return to sleep?_______

Racing thoughts

Inability to concentrate

Increased irritability

Worsening mood

Elevated mood

Hearing voices

Obsessive concerns

Significant change in mood since your last appointment         Suicidal thoughts or wishes

Change in appetite or base weight

Heart attack

Seizure

Hysterectomy

Hospitalization for any reason

Head injury, concussion

Deaths or serious illnesses in the family

Other major life stresses

 

 

Has your job or insurance coverage changed?__________

 

If your insurance has changed, please discuss this and provide information if I am a provider for your insurance plan.

 

 

 

Pulse_________              Height___________Weight___________BloodPressure___________________

 

S:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

O:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

APPEARANCE:             Neat      Disheveled         Fidgety              Psychomotor retarded       Other

MOOD                          Anxious             Depressed           Euthymic

                        Affect     Appropriate        Blunted             Flat

ORIENTATION             Person               Place                 Time

MEMORY                     Serial 7’s________Immediate recall_______#>, _______#< Delayed_______

THOUGHT PROCESSES                        Logical              Coherent            Disorganized

                                                Circumstantial    Tangential          Delusional

                                                Hallucinations

                                                Pressure of speech or thought

INTELLIGENCE, INSIGHT______________________________________________________________

ABNORMAL INVOLUNTARY MOVEMENTS                  present               absent

 

LAB__________________________________________________________________________________

 

Impression:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Plan:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sign_______________
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