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?
Do you have an upcoming med appointment?
Name
Date of Birth
Select the provider you'd like this form to go to
DEPRESSION: Low energy, motivation, or lack of pleasure
ANXIETY: Fear, worry, nervousness
Thoughts that life is not worthwhile
IRRITABILITY: Impatient, angry, quick to argue
HYPER: Energized, agitated, restless, or doing a lot more things than usual
IMPULSIVE: Doing things that are risky or that you might regret (overspending, aggressive driving, suddenly making major life changes)
Trouble making decisions
Procrastinating or avoiding tasks
Easily distracted or difficulty sustaining attention
Feeling like other people are out to get you
HALLUCINATIONS: Hearing or seeing things that other people don't
OBSESSIONS (disturbing thoughts, doubts, or images that intrude on your mind) or COMPULSIONS (checking, sorting, or cleaning things repeatedly)
If you need meds called in (otherwise we will mail to you)