Medication Visit Form

Name*

Date*

How many days have you felt well in the past week?*

Check any sleep problems you've had in the past week:

falling asleep
staying asleep
waking too early

Rate how you've felt over the past week for each item:

Depression, including lack of pleasure/motivation*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Inactive, withdrawing or not doing much*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Trouble making decisions, concentrating, planning or organizing*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Thoughts that you would be better off dead, or of hurting yourself*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Anxiety, fear, or nervousness*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Irritable, impatient, or argumentative*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Energized, agitated, restless, wired; or still active despite few hours of sleep*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

More hyper, driven, active, or doing a lot more than normal for you*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Doing things that others might think are risky, impulsive or excessive*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Rapid thoughts that move so fast it’s hard to follow them*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Difficulty sustaining attention (e.g. reading, lectures, conversation, TV)*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Distracted by noises around you or by your own thoughts*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Procrastinating, avoiding tasks, or not finishing them*

None
Mild (infrequent or rarely causes a problem)
Moderate (often or causes some problems)
Severe (contant or causes many problems)

Recent symptoms

Current Weight*

Mental: check any recent symptoms (regardless of their cause)

emotional numbing
paranoid sensations
panic attacks
hearing voices or seeing things
tired
memory problems

If you checked panic attacks, how many per week?

Sleep: check any recent symptoms (regardless of their cause)

needing more than 10 hours of sleep
needing less than 4 hours of sleep
vivid dreams
sleep-walking
snoring

Neurologic: check any recent symptoms (regardless of their cause)

General: check any recent symptoms (regardless of their cause)

flu-like feelings
sexual difficulties
physical pain

If you checked physical pain, rate it 1-10 (with 10 being worst)

Eyes: check any recent symptoms (regardless of their cause)

blurry vision
visual changes
double vision

Stomach: check any recent symptoms (regardless of their cause)

Skin: check any recent symptoms (regardless of their cause)

rash
acne
excess sweating
itch
easily sunburned
unusual bruising
hair loss

Heart: check any recent symptoms (regardless of their cause)

palpitations

Urinary: check any recent symptoms (regardless of their cause)

frequent urination
difficulty urinating

Female: check any recent symptoms (regardless of their cause)

menstrual changes
breast changes

Substances

Caffeine: How many cups per day?

Nicotine: How many packs per day?

Alcohol: How many drinks per day?

Sleep meds: number per week?

If taking any other meds as-needed for anxiety, how many do you use and often (per day, week, or month?

What other drugs have you used since your last visit?

Thank you for completing this. These ratings improve medication decisions (in one study they doubled recovery rates!). If you are taking new meds, or are missing doses of your psych meds, please let us know below.

Provider's Name*