Medication Visit Form

Name
Date of Birth
What type of visit is this for?

Over the past week did you have problems with...

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?
Hearing or seeing things that other people don't?
Have wished you were dead or wished you could go to sleep and not wake up?
Have you made plans or taken steps toward suicide?
How much have your current treatment(s) improved your life, symptoms, and your overall functioning?
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?