MEDICATION MONITORING FORM

Name: Standing Sitting Weight ID#: Height Heart Rate Blood Pressure:

List All Medications Being Taken at This Time

Center Medications

Other Prescribed Medications

Over Counter Medications

Other Medical Conditions

Yes No Lab Results:

Do you feel your medications are helping you? At this time client is If noncompliant compliant

non compliant with medication Unable to take medication Side Effects Skipping doses Other: Overtaking medication

Refusing to take medication(s) Out of Medication

Is medication controlling target symptom(s)?

Yes

No Delusional Thinking Hyperactive Depressed Irritable Other: Acting Out

Visual Hallucination Crying Spells Substance Use Yes Beck No

Sensory Hallucination Anxious ETOH Score

Cocaine MMSE

Side Effects/Adverse Reactions Reported

Cardiovascular Gastrointestinal Tachycardia/palpitations Nausea Constipation Central Nervous System Extra-pyramidal Symptoms If yes, type: Tardive Dyskinesia Referred to physician/therapist Headache Sedation Yes No Slowed Motion Muscle Stiffness Dystonia (Sudden Spasms) No No AIMS Scale/Discus Examination Next PMA: Tremors Date: Vomiting Abdominal Pain Nervousness Ataxia Dizziness Diarrhea Hot Flashes Dry Mouth Increased Salivation Insomnia Confusion Decrease in Appetite Bladder Problems Drowsiness Nightmares Increase in Appetite Indigestion Tremor Blurred Vision

Pseudo Parkinsonism Akathesia (Restlessness) Yes Yes

ALLERGIES: Indigent medication application (see PMO sheet)

Medication Education Done

Name Dosage Type Benefits Time to take Outcomes Expected Common Side Effects Reason for taking Access to care Pillminder Medication Information provided to Family/Caregiver Pharmacy: Bridge prescription/samples (see PMO sheet) If neuroleptic ordered, is Neuroleptic Consent Form in chart & signed by patient? Yes No

Physician Alert/ Nurse Comments

Work/School Excuse Staff ID# Date: Staff Signature: Time: Return Appt: Teachers Questionnaire Ticket #:

Date of Last Hospitalization:

SCDMH FORM June 2000 C-67

Comments:

SCDMH FORM June 2000 C-67