Download Initial Medication Face Sheet

Initial Medication Face Sheet
Case File #:_________
Analyst: __________________Supervisor: ______________________
Date Analysis Began: _________
DSM-IV Diagnosis:
If no DSM IV Dx present, Indications for Medication/Target Symptoms that are being treated:
1.
2.
3.
4.
Current Psychotropic Medication and dosage: (Rx and OTC)
Med Name
Dose
Date Began
Side Effects
Response
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
1
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
Who brought up the issue of medication?
 patient  analyst  supervisor
Who is the prescriber?
 current analyst
 other psychiatrist
 internist
 other
If the analyst is prescribing, do you consult with an outside psychopharmacologist?
____yes ____no
Was patient on psychotropic medication prior to this analysis?
 yes  no
if yes:
Who prescribed it for the patient?
 current analyst  other psychiatrist
 internist
 other
Who will now prescribe it?
 current analyst  other psychiatrist
 internist
 other
If patient was on psychotropic medication in the past, please complete Past Psychiatric Medication
History
Past History Information obtained from:
___analyst records ___patient recall ____other records
Overall, acquired information is judged to be:
___ reliable ___unreliable
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Past Psychotropic Medication and dosage: (Rx and OTC)
Med Name
Dose
Date
BeganD/C’d
Side Effects
Response
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
0 – not assessed
1 – very much improved (>85%)
2 – much improved (60-85%)
3 – minimally improved (20-25%)
4 – no change (+/- 15%)
5 – minimally worse (20-55%)
6 – much worse (60-80%)
7 –very much worse (>80%)
Medical History
Current Medical Problems/Diagnoses:
1.
2.
3.
Current Non-psychotropic Medications and dosage:
(Rx and OTC (including herbal supplements) but not psychotropics)
3
Med Name
Dose
Date
Began
Reason (diagnosis)
Side Effects
Past Medical History (with dates)
Serious Illnesses:
Hospitalizations:
Operations:
Current Drugs of Abuse:
(include EtOH, Nicotine, and other (please list))
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Name
EtOH
Nicotine
Quantity/frequency
Past Drugs of Abuse:
(include EtOH, Nicotine, and other (please list))
Name
Quantity/frequency
Date Began
Date
Began
Date
D/C’d
EtOH
Nicotine
Allergies:
Allergies to Medication:
Lab results (if indicated):
If Patient is female, what is her current contraception method?
5