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 or with difficulty breathing!
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
Do you take your medication daily as prescribed? __ Yes __ No
Have the benefits & purpose of medication been explained? __ Yes __ No Is additional training needed? __ Yes __ No Do you use alcohol and substances? __Yes __ No Comments___________________________________________________________________
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. In case of an emergency or severe reaction call 911.
__ Mood, stability,
__ Anxiety, panic
__ Muscle cramps
__ Suicidal, homicidal thoughts, or plans (call 911)
__ Restlessness, inability to sit still, pacing
__ Abnormal eye movements
__ Dry mouth
__ 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, (call 911)
__ Negative rumination, (negative thoughts on repeat in your head)
__ Skin rash
__ Nausea, vomiting
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?
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Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication, if necessary, and supportive therapy. Always share this material and your questions about this material with your doctor and therapist.