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REQUEST FIRST VISIT
PATIENT PORTAL
Medication Visit Form
Medication Visit Form
Please complete before your medication visit. We'll track your answers and, over time, they form patterns that help us guide your treatment.
You can read the answers to us, email a photo/scan to
[email protected]
, or fax to (336) 201-0538. There are also printable forms available at https://www.moodtreatmentcenter.com/forms/
What type of visit is this for?
Office Visit
Telemedicine Visit
Phone Consultation
Other
Do you have an upcoming med appointment?
Yes
No
Unsure
Name
First
Last
Date of Birth
Month
Day
Year
Provider
--Please Select--
Chris Aiken
Natasha Cooper
Laura Davis
Miriam Dineen
Allan Faircloth
Cliff Harper
Andrew Harris
Joe Harris
Kristen King
Larisa King
Brian McCarthy
Adam McDonough
Kellie Newsome
Valerie Vestal
Kadie York
Select the provider you'd like this form to go to
DEPRESSION: Low energy, motivation, or lack of pleasure
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
ANXIETY: Fear, worry, nervousness
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
Thoughts that life is not worthwhile
0 None
1 Mild thoughts of worthlessness
2 Moderate thoughts of worthlessness
3 Mild suicidal thoughts
4 Moderate suicidal thoughts
5 Active suicidal planning
6 Suicidal actions
IRRITABILITY: Impatient, angry, quick to argue
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
HYPER: Energized, agitated, restless, or doing a lot more things than usual
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
IMPULSIVE: Doing things that are risky or that you might regret (overspending, aggressive driving, suddenly making major life changes)
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
Trouble making decisions
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
Procrastinating or avoiding tasks
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
Easily distracted or difficulty sustaining attention
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
Feeling like other people are out to get you
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
HALLUCINATIONS: Hearing or seeing things that other people don't
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
OBSESSIONS (disturbing thoughts, doubts, or images that intrude on your mind) or COMPULSIONS (checking, sorting, or cleaning things repeatedly)
0 None
1 Mild-low
2 Mild-high
3 Moderate-low
4 Moderate-high
5 Severe-low
6 Severe-high
Physical symptoms or side effects?
Pharmacy Name and Location (city/street)
Pharmacy Phone
If you need meds called in (otherwise we will mail to you)
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