Medication Visit Form

Name
Date of Birth
What type of visit is this for?
Select the provider you'd like this form to go to

Rate how you've felt over the past week

0 = None
1= Yes, but normal level
2-3 = Mild (infrequent, rarely causes problems)
4-7 = Moderate (often or causes some problems)
8-10 = Severe (constant or causing many problems)

Mood Symptoms

DEPRESSION
Low energy, motivation, or lack of pleasure
ANXIETY
Fear, worry, nervousness
POOR SLEEP
Trouble sleeping or oversleeping
IRRITABLE
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 (spending, aggressively driving, suddenly making major life changes)

Cognition

Trouble making decisions or managing stress
Procrastinating or avoiding tasks
Easily distracted or difficulty sustaining attention

Other

Feeling like other people are out to get you
Hearing or seeing things that other people don't
OCD: Obsessions (disturbing thoughts, doubts or images that intrude your mind) or Compulsions (repeatedly checking, sorting, cleaning or other rituals)
HOPELESS: Thoughts that your life is hopeless or worthless, or suicidal thoughts or actions

Are you doing anything to improve your mental health, like...

Exercising
Healthy food?
Taking on challenges?
Out of bed in the morning?