Medication Visit Form

Name

First Last

Date of Birth

What type of visit is this for?

Office Visit

Telemedicine Visit

Phone Consultation

Other

Provider

Feeling low, hopeless, or depressed?

Obtaining pleasure from doing things or having little interest in doing things?

Anxiety, nervousness, or feeling on edge or jumpy?

Excessive worrying?

Falling or staying asleep?

Agitation, anger, or irritability?

Concentration, attention, or distractibility?

Feeling like people are plotting against you, trying to hurt you, or spying on you?

Yes

No

Maybe

Hearing or seeing things that other people don't?

Yes

No

Maybe

Have wished you were dead or wished you could go to sleep and not wake up?

Yes

No

Maybe

Have you made plans or taken steps toward suicide?

Yes

No

Maybe

How much have your current treatment(s) improved your life, symptoms, and your overall functioning?

A great deal better, and a considerable improvement that has made all the difference

Better, with a definite improvement that has made a real and worthwhile difference

Moderately better, and a slight but noticeable difference

Somewhat better, but the change has not made any real difference

A little better, but no noticeable change

Almost the same, hardly any change at all

No change or worse

How many times in the past MONTH did you have 4 or more alcoholic drinks a day (for a woman) or 5 or more alcoholic drinks a day (for a man)?

How many times in the past MONTH did you use recreational drugs or prescription drugs for nonmedical reasons?

Any physical symptoms or side effects that are bothering you?

Weight

Nicotine Use

New health problems? New medications? Or taking your psych meds differently than prescribed?

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