Psychiatric visit reporting form

James E. DelGenio MS, LCPC

Doctor reporting form. Help the Doctor help you.

Copy and present this to the doctor at each visit. This list is not all inclusive; report anything which may be useful for your treatment. Call 911 in case of emergency.

Name: ______________________________  Date: ____________

Indicate areas (“X”) in which you feel you need training and education:
1.__ Depression, Mood Disorder, Serious MI
2.__ Use of Psychiatric Medication
3.__ Alcohol, Drug Abuse and Addiction
4.__ Medication Side Effects
5.__ Adverse Reactions
6.__ Dual Diagnosis – MI & Alcohol/Substance Abuse
7.__ Storage of Medication, Safe Guarding Medication
8.__ Medical Emergencies
9.__ Questions About Medications
10.__ Other, ________

Do you take your medication daily as prescribed? __ Yes __ No
Have the benefits and purpose of medication been explained?    __ Yes __ No
Is additional training needed? __ Yes __ No

Fill in all boxes below with one of the following codes
NA = Not applicable, no problem noted
U = Unable to determine
X = Problem noted, see comments
S = Symptoms

Common Issues, Symptoms & Possible Medication Side Effects
__ Mood, stability
__ Swelling                                                                                                     __ Nausea, vomiting
__ Constipation,
__ Diarrhea
__ Anxiety, panic
__ Muscle cramps
__ Headache
__ Suicidal, homicidal thoughts
__ Restlessness, inability to sit still, pacing
__ Abnormal eye movements
__ Dry mouth
__ Tremor
__ Blurred vision
__ Sexual dysfunction
__ Relationship issues, conflict
__ Menstrual problems
__ Urinary retention
__ Depression, mood swings
__ Anger, irritability, hostility
__ Appetite loss, increased appetite
__ Involuntary weight changes
__ Employment issues
__ Poor concentration
__ Poor short term memory
__ Social isolation, withdrawal
__ Eye photo-sensitivity
__ Poor Concentration
__ Hearing voices
__ Poor daily functioning
__ Skin photo-sensitivity
__ Sleep/wake cycle, poor sleep, no sleep
__ Difficulty swallowing or breathing
__ Suicidal thoughts
__ Skin rash
__ Other, ______________________________________________________________________________________________________________________________________________________________

Additional comments and concerns: Include: (1) Alcohol and drug use (2) Medication compliance (3) Suicidal or homicidal thoughts or plan (4) Other issues, reactions, side effects or Questions?

For those in the metropolitan Chicago area, I have offices on Michigan Avenue, Chicago and Westchester. Call 847- 733-4300 Ext 638.

http://manageyourmood.net
http://family-institute.org
http://psychologytoday.com

Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication and supportive therapy. Always share this material and your questions about this material with your doctor and therapist.

Comments 1

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