Dear Dr

Name:

Claim #:

Date of Injury:

Please Print Name of Medical Evaluator:

RESIDUAL FUNCTIONAL CAPACITY

SIDE EFFECTS OF MEDICATION

Medical Specialty:

What is the first date patient’s impairment(s) became “severe” meaning that his/her impairment(s) caused interference ADL’s or ability to work?

When did you begin treating the patient?

How frequently do you see your patient?

Date:

Date:

Date:

Claimant reported taking the following medication(s) for his or her medical condition(s):









Claimant reported the following side effects from the medication(s):









SIDE EFFECTS OF MEDICATIONS

Is your patient taking prescribed medication listed above for his/her industrial condition(s):

Other:

Is there a reasonable medical probability your patient will experience side effects from the industrial medication(s) listed above?

Other:

YES

YES

NO

NO

Is your patient taking medication(s) non-industrial prescribed medications?

If yes, please list:

Is there a reasonable medical probability your patient will experience side effects from the nonindustrial medications, if any?

If yes, please explain:

YES

YES

NO

NO

In utilizing this form, please assume the following definitions:

“Mild” annoyance but no reduction in the ability to perform the function.

“Slight” noticeable impairment

“Severe” inability to perform the function.

For the following questions please assume that “off task” means an inability and/or a reduction in productivity over the course of an 8 hour work day. If appropriate, please choose one of the 4 following definitions of “Moderate” you feel best describes claimant’s impairments taking into account the industrial medications, if any:

1.

2.

3.

Will be “off task” up to 10% of the time in an 8 hour day;

Will be “off task” up to 15% of the time in an 8 hour day;

Will be “off task” up to 20% or more of the time in an 8 hour day;

4.

Other: Will be “off task” % of the time in an 8 hour day;

To what degree will the side effects impair claimant’s ability for concentration, persistence pace separate and apart from the underlying industrial medical condition(s)?

Mild Slight Moderate Severe Other:

To what degree will the side effects impair claimant’s ability for concentration, persistence and pace in combination with the underlying industrial medical condition(s)?


1

If/when side effects exist can you estimate the severity?


Hours <1 2 3 4 5 6 7 8

Approximate duration of the most severe side effect(s):

Is claimant allowed to operate machinery or motorized vehicles when experiencing side effects from medication(s), if any?

Yes No Other:

Is there a reasonable medical probability that the side effects of medication(s) will:

Impair claimant’s capacity to perform work to a minimum standard of productivity ? If yes, to what degree:


Impair claimant’s capacity to perform detailed work requiring hand/eye coordination ? If yes, to what degree:


Impair claimant’s cognitive acuity and/or ability to focus on activities such as reading, writing, or computer use?

If yes, to what degree:


Result in fatigue ? If yes, to what degree:


Result in claimant becoming lethargic ? If yes, to what degree:


I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the report accurately describes the information provided to me and except as noted herein, that I believe it to be true. I also declare under the perjury that this physician has no violated section 139.3 of the Labor Code.

My opinions are expressed to a degree of medical probability, unless otherwise stated.

Signature of Physician ____________________________________ Date

Additional Comments:

2

EXAMPLES OF MEDCATIONS AND THE POTENTIAL SIDE EFFECTS AS REPORTED BY Web MD at: http://www.webmd.com

.

Adderall; Ambien; Amitriptyline; Amoxicillin; Atenolol; Ativan; Bentyl; Celexa; Cephalexin; Clonazepam; Clonidine;

Cymbalta; Diazepam; Dilaudid; Ditropan ; Effexor; Famotidine; Fentanyl; Flexeril; Furosemide; Gabapentin;

Hydrochlorothiazide; Hydrocodone; Hydromorphone; Kadian; Klonopin; Lactulose; Lasix; Levitra; Lexapro; Lidoderm;

Lipitor; Lisinopril; Lodine; Lorazepam; Lyrica; Metformin; Methadone; Methocarbamol; Metoprolol; Minoxidil; Mobic;

Morphine; Neurontin; Naproxen; Nifedical; Niravam; Nizatidine; Norco; Norvasc; Omeprazole (Prilosec); Opana;

Oxycodone; OxyContin; Paroxetine; Paxil; Percocet; Phentermine; Polyethylene Glycol; Potassium; Prednisone; Protonix;

Prozac; Ritalin; Senna with Docusate Sodium; Seroquel; Sertraline; Skelaxin; Soma; Spironolactone; Testim; Tizanidine;

Topamax; Topical Corticosteroids for Atopic Dermatitis; Tramadol; Trazodone; Ultram; Valium; Vicodin; Wellbutrin;

Xanax; Zoloft

Medication

Adderall

Ambien

Amitriptyline

Amoxicillin

Atenolol

Ativan

Bentyl

Celexa

Cephalexin

Clonazepam

Clonidine

Side Effects

Common side effects: Chronic Trouble Sleeping; Nervous; Easily Angered or Annoyed; False

Sense of Well-Being. Infrequent side effects: Blurred Vision; Dry Mouth; Incomplete or

Infrequent Bowel Movements; Inability to have an Erection; Dizzy; Excessive Sweating; Taste

Problems; Loss of Appetite; Weight Loss; Head Pain; Fast Heartbeat; Heart Throbbing or

Pounding; Feel like Throwing Up; Throwing Up; diarrhea; Stomach Cramps; Feeling Weak;

Sexual Problems; Altered Interest in Having Sexual Intercourse.

Common side effects: Hiccups. Infrequent side effects: Nightmares; Double Vision; Problems with Eyesight; Dry mouth; Indigestion; Urinary Tract Infection; Joint Pain; Muscle Pain;

Drowsiness; Loss of Memory; Sensation of Spinning or Whirling; Dizzy; Head Pain; Feel Like

Throwing Up; Throwing Up; Diarrhea; Stomach Cramps; Feeling Weak; Not Feeling Well.

Common side effects: Dry Mouth; Drowsiness; Dizzy; Taste Problems; Weight Gain;

Increased Hunger; Head Pain. Infrequent side effects: Incomplete or Infrequent Bowel

Movements; Chronic Trouble Sleeping; Excessive Sweating; Throwing Up; Heartburn;

Diarrhea.

Common side effects: Head Pain; Thrush; Yeast Infection of Vagina or Vulva; Feel Like

Throwing Up; Throwing Up; Diarrhea. Infrequent side effects: Itching; Stomach Cramps.

Common side effects: Drowsiness; Chronic Trouble Sleeping; Low Energy; Feeling Weak;

Sexual Problems. Infrequent side effects: Stuffy Nose; Incomplete or Infrequent Bowel

Movements; Feel Like Throwing Up; Throwing Up; Diarrhea; Stomach Cramps; Nervous;

Anxious.

Common side effects: Drowsiness; Dizzy; Slurred Speech. Infrequent side effects: Low

Energy; Uncoordinated; Feeling Weak.

Common side effects: Dry Mouth; Incomplete or Infrequent Bowel Movements; Decreased

Sweating. Infrequent side effects: Blurred Vision; Dilated Pupil; Decreased Breast Milk

Production; Drowsiness.

Common side effects: Inability to have an Erection; Sexual Problems; Altered Interest in

Having Sexual Intercourse; Problem with Ejaculation; Dry Mouth; Drowsiness; Chronic

Trouble Sleeping; Feel Like Throwing Up. Infrequent side effects: Feeling Restless; Blurred

Vision; Problem with Periods; Itching; Loss of Memory; Fever; Rash; Trouble Breathing;

Excess Urination; Confused; Grinding of the Teeth; Blood Pressure Drop Upon Standing;

Inflammation of the Nose; Sinus Irritation and Congestion; Increased Production of Saliva;

Indigestion; Joint Pain; Muscle Pain; Low Energy; Excessive Sweating; Involuntary Quivering;

Taste Problems; Loss of Appetite; Weight Gain; Weight Loss; Yawning; Throwing Up; Gas;

Diarrhea; Stomach Cramps; Numbness and Tingling; Feeling Weak; Anxious.

Common side effects: Yeast Infection of Vagina and Vulva; Diarrhea. Infrequent side effects:

Thrush; Feeling Like Throwing Up; Throwing Up; Stomach Cramps.

Common side effects: Drowsiness; Dizzy; Slurred Speech. Infrequent side effects: Depression;

Muscle Weakness; Confused; Low Energy; Uncoordinated; Feeling Weak

Common side effects: Dry Mouth; Incomplete or Infrequent Bowel Movements; Drowsiness;

Dizzy; Low Energy; Feeling Weak. Infrequent side effects: Dry eye; Eye Irritation; Eye

Itching; Blood Pressure Drop Upon Standing; Inability to have an Erection; Loss of Appetite;

3

Cymbalta

Diazepam

Dilaudid

Ditropan

Doxazosin

Effexor XR

Famotidine

Fentanyl Patch

Flexeril

Furosemide

Gabapentin

Feeling Like Throwing Up; Throwing Up; Nervous; Sexual Problems.

Common side effects: Dry Mouth; Incomplete or Infrequent Bowel Movements; Drowsiness;

Dizzy; Chronic Trouble Sleeping; Low Energy; Excessive Sweating; Loss of Appetite; feel

Like Throwing Up; Diarrhea. Infrequent side effects: Orgasm Problems; Blurred Vision;

Itching; Hair Loss; Acne; Cramps; Involuntary Quivering; Temporary Redness of Face and

Neck; Weight Loss; Throwing Up; Difficult or Pain Urination; Anxious; Problem with

Ejaculation.



Common side effects: Abnormally Low Blood Pressure; Drowsiness; Feeling Faint; Dizzy;

Loss of Appetite; Feeling Weak; Not Feeling Well. Infrequent side effects: Slow Heartbeat;

Vocal Cord Swelling; A Spasm of the Larynx; Collapsed Portion of Lung; Significant Decrease in Lung Function; Bronchospasm; Fast Heartbeat; Change in Pulse; Involuntary Muscle

Movements; Confused; Double Vision; Blurred Vision; Problems with Eyesight; Dry Mouth;

Irritation of the Stomach or Intestines; Incomplete or Infrequent Bowel Movements; Spasm of a Bile Duct Tract; Spasm of the Ureter or Tube Connecting Kidney to Bladder; Head Pain; Feel

Like Throwing Up; Throwing Up; Kidney Problems Causing a Decreased Amount of Urine to be Passed; Nervous; False Sense of Well-Being.

Common side effects: Dryness of the Nose; Dry Mouth; Incomplete or Infrequent Bowel

Movements; Decreased Sweating; Drowsiness; Throat Dryness; Feel Like Throwing Up.

Infrequent side effects: Urinary Tract Infection; Blurred Vision; Dry Eye; Inflammation of the

Nose; Indigestion; Backache; Dizzy; Flu-Like Symptoms; Pain; Diarrhea; Difficult or Painful

Urination; Stomach Cramps.

Common side effects: Sensation of Spinning or Whirling; Dizzy; Low Energy; Head Pain.

Infrequent side effects: Abnormal Heart Rhythm; Blood Pressure Drop Upon Standing; Fluid

Retention in the Legs, Feet, Arms or Hands; Fast Heartbeat; Heart Throbbing or Pounding;

Trouble Breathing; Inflammation of the Nose; Drowsiness; Feel Like Throwing Up; Nervous;

Easily Angered or Annoyed.

Common side effects: Nightmares; Inflammation of the Nose; Dry Mouth; Indigestion;

Incomplete or Infrequent Bowel Movements; Drowsiness; Dizzy; Chronic Trouble Sleeping;

Excessive Sweating; Chills; Involuntary Quivering; Taste Problems; Loss of Appetite; Weight

Loss; Feel Like Throwing Up; Throwing Up; Gas; Diarrhea; Stomach Cramps; Nervous;

Numbness and Tingling; Feeling Weak; Anxious. Infrequent side effects: Neck Pain;

Twitching; Visible Water Retention; Weight Gain.

Common side effects: Head Pain. Infrequent side effects: Incomplete or Infrequent Bowel

Movements; Diarrhea.

Common side effects: Hallucination; Fever; Periods of Not Breathing; Trouble Breathing;

Cannot Empty Bladder; Abnormal Nervous System Function Affecting Mental Alertness; Dry

Mouth; Conditions of Excess Stomach Acid Secretion; Incomplete or Infrequent Bowel

Movements; Itching; Drowsiness; Dizzy; Excessive Sweating; Loss of Appetite; Head Pain;

Feel Like Throwing Up; Throwing Up; Diarrhea; Stomach Cramps; Nervous; Feeling Weak;

Confused; Anxious; False Sense of Well-Being. Infrequent side effects: Depression; Unsteady

Walking; Abnormal Heart Rhythm; Abnormally Low Blood Pressure; Acute Infection of the

Nose, Throat or Sinus; Significant Decrease in Lung Function; Feeling Faint; Voluntary

Movement Difficulty; Slurred Speech; Coughing Up Blood; Chest Pain; Signs and Symptoms at Injection Site; Paranoia; Nightmares; Feeling Restless; Stinging of Skin; Throat Irritation;

Loss of Memory; Low Energy; Flu-Like Symptoms; Bloating.

Common side effects: Blurred Vision; Dry Mouth; Drowsiness; Dizzy.

Common side effects: Blood Pressure Drop Upon Standing. Infrequent side effects: Low

Amount of Magnesium in the Blood; Low Amount of Calcium in the Blood; Low Amount of

Sodium in the Blood; Low Amount of Potassium in the Blood; Imbalance in Body Salts like

Potassium and Sodium; Low Amount of Chloride in the Blood; Blurred Vision; Dry Mouth;

Sun-Sensitive Skin; Cramps; Drowsiness; Dizzy; Loss of Appetite; Head Pain; Diarrhea;

Stomach Cramps.

Common side effects: Double Vision; Blurred Vision; Problems with Eyesight; Muscle Pain;

4

Hydrochlorothiazide

Hydrocodone Compound

Oral

Hydromorphone

Kadian

Klonopin

Lactulose

Lasix

Levitra

Lexapro

Lidoderm

Lipitor

Lisinopril

Lodine

Drowsiness; Dizzy; Low Energy; Involuntary Quivering; Fluid Retention in the Legs, Feet,

Arms or Hands.

Infrequent side effects: Blood Pressure Drop Upon Standing; Sun-Sensitive Skin; Loss of

Appetite; Diarrhea; Stomach Cramps; Sexual Problems.

Common side effects: lightheadedness, dizziness, drowsiness, vision changes, vomiting, and constipation.


Loss of Appetite; Feeling Weak; Not Feeling Well. Infrequent side effects: Slow Heartbeat;

Vocal Cord Swelling; A Spasm of the Larynx; Collapsed Portion of Lung; Significant Decrease in Lung Function; Bronchospasm; Fast Heartbeat; Change in Pulse; Involuntary Muscle


Irritation of the Stomach or Intestines; Incomplete or Infrequent Bowel Movements; Spasm of a Bile Duct Tract; Spasm of the Ureter or Tube Connecting Kidney to Bladder; Head Pain; Feel

Like Throwing Up; Throwing Up; Kidney Problems Causing a Decreased Amount of Urine to be; Passed; Nervous; False Sense of Well-Being.

Common side effects: Abnormally Low Blood Pressure; Incomplete or Infrequent Bowel

Movements; Drowsiness; Feeling Faint; Dizzy; Feel Like Throwing Up; Throwing Up.

Infrequent side effects: Slow Heartbeat; Vocal Cord Swelling; A Spasm of the Larynx;

Collapsed Portion of Lung; Significant Decrease in Lung Function; Bronchospasm;

Inflammation of Skin caused by an Allergy; Itching; Hives; Rash; Fast Heartbeat; Change in

Pulse; Trouble Breathing; Giant Hives; Reaction due to an Allergy; Involuntary Muscle


Irritation of the Stomach or Intestines; Spasm of a Bile Duct Tract; Spasm of the Ureter or

Tube Connecting Kidney to Bladder; Loss of Appetite; Head Pain; Kidney Problems Causing a

Decreased Amount of Urine to be Passed; Nervous; Feeling Weak; Not Feeling Well; False

Sense of Well-Being.



Infrequent side effects: Excessive Thirst; Gas; Diarrhea; Stomach Cramps.

Common side effects: Blood Pressure Drop Upon Standing Infrequent side effects: Low

Amount of Sodium in the Blood; Low Amount of Potassium in the Blood; Imbalance in Body

Salts like Potassium and Sodium; Low Amount of Chloride in the Blood; Blurred Vision; Sun-

Sensitive Skin; Loss of Appetite; Head Pain; Diarrhea; Stomach Cramps.

Common side effects: Inflammation of the Nose; Indigestion; Temporary Redness of Face and

Neck; Head Pain. Infrequent side effects: Backache; Sinus Irritation and Congestion; Dizzy;

Flu-Like Symptoms; Feel Like Throwing Up.

Common side effects: Dry Mouth; Conditions of Excess Stomach Acid Secretion; Incomplete or Infrequent Bowel Movements; Inability to have an Erection; Drowsiness; Dizzy; Chronic

Trouble Sleeping; Low Energy; Excessive Sweating; Feel Like Throwing Up; Diarrhea;

Altered Interest in Having Sexual Intercourse; Problem with Ejaculation. Infrequent side effects: Inflammation of the Nose; Sinus Irritation and Congestion; Flu-Like Symptoms; Loss of Appetite; Stomach Cramps; Sexual Problems.

Common side effects: Complication at Treatment Site.

Common side effects: Indigestion; Incomplete or Infrequent Bowel Movements; Gas; Stomach

Cramps. Infrequent side effects: Throat Irritation; Sinus Irritation and Congestion; Dizzy; Flu-

Like Symptoms; Rash; Head Pain; Feel Like Throwing Up; Diarrhea.

Common side effects: Head Pain; Cough. Infrequent side effects: Acute Infection of the Nose,

Throat or Sinus; Stuffy Nose; Indigestion; Inability to have an Erection; Cramps; Sensation of

Spinning or Whirling; Low Energy; Taste Problems; Feel Like Throwing Up; Throwing Up;

Diarrhea; Numbness and Tingling; Feeling Weak; Altered Interest in Having Sexual

Intercourse.

Common side effects: Conditions of Excess Stomach Acid Secretion; Dizzy; Low Energy;

Head Pain; Feel Like Throwing Up; Gas; Diarrhea; Stomach Cramps. Infrequent side effects:

Depression; Double Vision; Blurred Vision; Problems with Eyesight; Ringing in the Ears;

Ulcers of Esophagus; Stomach Ulcer; Ulcer from Stomach Acid; Stomach or Intestinal Ulcer;

5

Lorazepam

Lyrica

Metformin

Methadone

Methocarbamol

Metoprolol

Minoxidil

Mobic

Morphine

Neurontin

Naproxen

Nifedical

Niravam

Nizatidine

Norco

Burning Stomach; Red Blood in Bowel Movement; Bleeding of the Stomach or Intestines;

Itching; Mental Impairment; Fever; Rash; Throwing Up Blood; Difficult or Painful Urination;

Frequent Urination; Mood Changes; Incomplete or Infrequent Bowel Movements; Bloating;

Nervous; Easily Angered or Annoyed.



Common side effects: Dizzy. Infrequent side effects: Dry Mouth; Incomplete or Infrequent

Bowel Movements; Pain; Head Pain; Injury; Feeling Weak.

Common side effects: Acute Infection of the Nose, Throat or Sinus; Taste Problems; Loss of

Appetite; Weight Loss; Head Pain; Feel Like Throwing Up; Throwing Up; Gas; Bloating;

Diarrhea; Stomach C ramps. Infrequent side effects: Inflammation of the Nose; Indigestion;

Incomplete or Infrequent Bowel Movements; Dizzy.


Movements; Drowsiness; Feeling Faint; Dizzy; Feel Like Throwing Up; Throwing Up; Feeling

Weak; Not Feeling Well. Infrequent side effects: Double Vision; Blurred Vision; Problems with Eyesight; Blood Pressure Drop Upon Standing; Dry Mouth; Irritation of the Stomach or

Intestines; Spasm of a Bile Duct Tract; Spasm of the Ureter or Tube Connecting Kidney to

Bladder; Chronic Trouble Sleeping; Excessive Sweating; Loss of Appetite; Head Pain; Kidney

Problems Causing a Decreased Amount of Urine to be Passed; Nervous; False Sense of Well-

Being.

Common side effects: Stomach Upset; Nausea; Flushing; constipation; Headache; Blurred

Vision; Lightheadedness; Dizziness or Drowsiness.

Common side effects: dizziness; lightheadedness; drowsiness; tiredness; diarrhea; vomiting; unusual dreams; trouble sleeping; or vision problems.

Common side effects: Abnormal Heart Rhythm; Visible Water Retention; Temporary Redness of Face and Neck; Water Retention; Excessive Hairiness. Infrequent side effects: Angina;

Inflammation of the Covering of the Heart or Pericardium; Chest Pain.

Common side effects: Stomach upset, nausea, drowsiness, or diarrhea


Movements; Drowsiness; Feeling Faint; Dizzy; Feel Like Throwing Up; Throwing Up.

Infrequent side effects: Double Vision; Blurred Vision; Problems with Eyesight; Dry Mouth;

Irritation of the Stomach or Intestines; Spasm of a Bile Duct Tract; Spasm of the Ureter or

Tube Connecting Kidney to Bladder; Loss of Appetite; Head Pain; Kidney Problems Causing a

Decreased Amount of Urine to be Passed; Nervous; Feeling Weak; Not Feeling Well; False

Sense of Well-Being.

Common side effects: Double Vision; Blurred Vision; Problems with Eyesight; Muscle Pain;

Drowsiness; Dizzy; Low Energy; Involuntary Quivering; Fluid Retention in the Legs, Feet,

Arms or Hands.

Common side effects: Incomplete or Infrequent Bowel Movements; Drowsiness; Feeling Faint;

Dizzy; Head Pain; Feel Like Throwing Up; Heartburn; Stomach Cramps. Infrequent side effects: Conditions of Excess Stomach Acid Secretion; Indigestion; Problem with Periods;

Sensation of Spinning or Whirling; Excessive Sweating; Heart Throbbing or Pounding;

Diarrhea.

Common side effects: Fluid Retention in the Legs, Feet, Arms or Hands; Dizzy; Temporary

Redness of Face and Neck; Head Pain; Feel Like Throwing Up. Infrequent side effects:

Chronic Heart Failure; Fluid in the Lungs; Fast Heartbeat; Incomplete or Infrequent Bowel

Movements; Low Energy.

Common side effects: Drowsiness; Inducing of a Relaxed Easy State; Dizzy; Slurred Speech.

Infrequent side effects: Depression; Difficulty Speaking; Confused; Painful Periods; Joint Pain;

Pain in Arms or Legs; Low Energy; Voluntary Movement Difficulty; Numbness and Tingling;

Sexual Problems.

Common side effects: Drowsiness. Infrequent side effects: Excessive Sweating.


Feeling Weak; Not Feeling Well. Infrequent side effects: Double Vision; Blurred Vision;

Problems with Eyesight; Dry Mouth; Incomplete or Infrequent Bowel Movements; Spasm of

6

Norvasc

Omeprazole

(Prilosec)

Opana

Oxycodone

OxyContin

Paroxetine - Oral

Paxil

Percocet

Phentermine

Polyethylene Glycol

Potassium

Prednisone

Protonix

Prozac

Ritalin the Ureter or Tube Connecting Kidney to Bladder; Loss of Appetite; Head Pain; Feel Like

Throwing Up; Throwing Up; Kidney Problems Causing a Decreased Amount of Urine to be

Passed; Nervous; False Sense of Well-Being; Narcotic Addiction.

Common side effects: Visible Water Retention; Temporary Redness of Face and Neck; Head

Pain. Infrequent side effects: Drowsiness; Low Energy; Feel Like Throwing Up; Stomach

Cramps.

Common side effects: Stomach Cramps. Infrequent side effects: Abnormal Heart Rhythm;

High Blood Pressure; Incomplete or Infrequent Bowel Movements; Itching; Drowsiness;

Dizzy; Head Pain; Chest Pain; Feel Like Throwing Up; Throwing Up; Gas; Diarrhea; Feeling

Weak.

Common side effects: Nausea; Vomiting; Fever; Constipation; Increased Sweating;

Lightheadedness; Dizziness; Drowsiness.


Feel Like Throwing Up; Throwing Up; Feeling Weak; Not Feeling Well. Infrequent side effects: Dry Mouth; Indigestion; Incomplete or Infrequent Bowel Movements; Spasm of the

Ureter or Tube Connecting Kidney to Bladder; Fever; Excessive Sweating; Head Pain; Kidney

Problems Causing a Decreased Amount of Urine to be Passed; Nervous.





Common side effects: Nausea, drowsiness, dizziness, trouble sleeping, loss of appetite, weakness, tiredness, dry mouth, sweating, yawning, or headache.

Comment side effects: Dry mouth; Incomplete or Infrequent Bowel Movements, Drowsiness,

Dizzy, Chronic Trouble Sleeping, Excessive Sweating, Involuntary Quivering, Loss of

Appetite, Head Pain, Feel Like Throwing Up, Diarrhea, Difficult or Painful Urination, Cannot

Empty Bladder, Frequent Urination, Nervous, Feeling Weak, Sexual Problems, Problem with

Ejaculation. Infrequent side effects: Blurred Vision, Inflammation of the Nose, Inability to have an Erection, Backache, Abnormal Increase in Muscle Tone, Taste Problems, Weight

Gain, Weight Loss, Increased Hunger, Fast Heartbeat, Cough, Gas, Stomach Cramps,

Numbness and Tingling, Anxious, Altered Interest in Having Sexual Intercourse.





Common side effects: Chronic Trouble Sleeping; Nervous; False Sense of Well-Being.

Infrequent side effects: Blurred Vision; Abnormal Heart Rhythm; Dry Mouth; Incomplete or

Infrequent Bowel Movements; Drowsiness; Dizzy; Head Pain; Diarrhea; Difficult or Painful

Urination; Stomach Cramps; Altered Interest in Having Sexual Intercourse.

Consult your pharmacist.

Common side effects: Feel Like Throwing Up; Throwing Up; Gas; Diarrhea; Stomach Cramps.

Infrequent side effects: High Amount of Potassium in the Blood.

Common side effects: Stomach upset, headache, dizziness, trouble sleeping, or weight gain.

Common side effects: Head Pain; Diarrhea. Infrequent side effects: Not Feeling Well.

Common side effects: Nausea, drowsiness, dizziness, anxiety, trouble sleeping, loss of appetite, weakness, tiredness, sweating, or yawning.

Common side effects: High Blood Pressure; Fast Heartbeat; Upper Abdominal Pain; Dry

Mouth; Chronic Trouble Sleeping; Loss of Appetite; Head Pain; Feel Like Throwing Up;

Nervous; Over Excitement. Infrequent side effects: Angina; Sinus Irritation and Congestion;

Inflammation of Skin caused by an Allergy; Hives; Joint Pain; Fever; Involuntary Quivering;

Voluntary Movement Difficulty; Rash; Chest Pain; Reaction due to an Allergy; Decreased

Blood Platelets; Throat Irritation; Acute Infection of the Nose, Throat or Sinus; Drowsiness;

Dizzy; Excessive Sweating; Weight Loss; Cough; Stomach Cramps.

7

Senna with Docusate

Sodium - Oral

Seroquel

Sertraline

Skelaxin

Soma

Spironolactone

Testim

Tizanidine

Topamax

Topical Corticosteroids for Atopic Dermatitis

Tramadol

Common side effects: Diarrhea, nausea, vomiting, abdominal cramps, or bloating.

Common side effects: Blood Pressure Drop Upon Standing; Stuffy Nose; Dry Mouth;

Indigestion; Incomplete or Infrequent Bowel Movements; Drowsiness; Dizzy; Chronic Trouble

Sleeping; Weight Gain. Infrequent side effects: Problems with Eyesight; Throat Irritation;

Inflammation of the Nose; Abnormal Increase in Muscle Tone; Excessive Sweating;

Involuntary Quivering; Loss of Appetite; Head Pain; Fast Heartbeat; Heart Throbbing or

Pounding; Difficulty Swallowing; Stomach Cramps; Feeling Weak; High Cholesterol; High

Amount of Triglyceride in the Blood.

Common side effects: Inability to have an Erection; Sexual Problems; Altered Interest in

Having Sexual Intercourse; Dry Mouth; Drowsiness; Dizzy; Chronic Trouble Sleeping; Low

Energy; Excessive Sweating; Involuntary Quivering; Loss of Appetite; Weight Loss; Head

Pain; Feel Like Throwing Up; Gas; Diarrhea; Stomach Cramps; Feeling Weak. Infrequent side effects: Feeling Restless; Blurred Vision; Problems with Eyesight; Incomplete or Infrequent

Bowel Movements; Temporary Redness of Face and Neck; Increased Hunger; Yawning;

Throwing Up; Nervous; Anxious.

Common side effects: Stomach Upset; Nausea; Constipation; Dry Mouth; Headache; Blurred

Vision; Lightheadedness; Dizziness; Drowsiness.

Common side effects: Dizziness; Drowsiness; Headache; Unusually Fast Heartbeat; Low Blood

Pressure; Face Flushing.

Common side effects: High Amount of Potassium in the Blood; Irritation of the Stomach or

Intestines. Infrequent side effects: Inability to have an Erection; Enlarged Breasts in Males;

Dizzy; Voluntary Movement Difficulty; Head Pain; Low Amount of Sodium in the Blood;

Sexual Problems.

Common side effects: Bladder Contractions Causing Frequent Passing of Urine; Urinary Tract

Infection; Continued Painful Erection; Enlarged Breasts in Males; Breast Tenderness; Absence of Menstrual Periods; Irregular Periods; Masculinization. Infrequent side effects: Liver

Problems; Enlarged Prostate; Epididymitis; Dizzy; Low Energy; Visible Water Retention;

Temporary Redness of Face and Neck; Head Pain; Feel Like Throwing Up; Throwing Up;

Cancer of the Prostate Gland; High Amount of Calcium in the Blood; Increased Risk of

Bleeding; High Blood Pressure; Inability to have an Erection; Decrease in Size of a Testicle;

Genital Itching; Itching; Increase in the Amount of Pubic Hair; Acne; Chronic Trouble

Sleeping; Skin Irritation; Diarrhea; Stomach Cramps; Feeling Weak; Altered Interest in Having

Sexual Intercourse.

Common side effects: Hepatitis caused by Drugs; Urinary Tract Infection; Skin Ulcer; Fever,

Nervous; Numbness and Tingling; Depression; Blood Pressure Drop Upon Standing; Throat

Irritation; Inflammation of the Nose; Dry Mouth, Indigestion; Incomplete or Infrequent Bowel

Movements; Backache; Muscle Weakness; Drowsiness; Dizzy; Excessive Sweating; Voluntary

Movement Difficulty; Rash; Difficulty Speaking; Throwing Up; Diarrhea; Stomach Cramps;

Feeling Weak; Anxious. Infrequent side effects: Visual Field Defect; Problems with Eyesight;

Vision Changes caused by Medications; Pain in the Eye; Abnormal Heart Rhythm; Acute

Infection of the Nose, Throat or Sinus; Bleeding of the Stomach or Intestines; Kidney Stone;

Mental Impairment; Hallucination; Feeling Faint; Seizures; Infection due to the Candida

Fungus; Underactive Thyroid; Anemia; Decreased White Blood Cells; Increase of White Blood

Cells; Blood Disorder; Delusions; Feeling Restless; Migraine Headache; Hair Loss; Dry Skin;

Arthritis; Neck Pain; Abscess; Involuntary Quivering; Visible Water Retention; Weight Loss;

Difficulty Swallowing; Mood Changes; Loss of One's Own Sense of Reality or Identity.

Common side effects: Weakness, tiredness, drowsiness, dizziness, confusion, difficulty concentrating, tingling of the hands/feet, loss of appetite, diarrhea, impotence, and weight loss.

Common side effects: Burning sensation, itching, irritation, dryness, or redness may develop in the area where the medicine is applied.

Infrequent side effects: Extreme Sense of Well Being; Widening of Blood Vessels; Dry Mouth;

Indigestion; Incomplete or Infrequent Bowel Movements; “Change of Life” Signs; Drowsiness;

Dizzy; Chronic Trouble Sleeping; Excessive Sweating; Voluntary Movement Difficulty; Rash;

Loss of Appetite; Head Pain; Feel Like Throwing Up; Throwing Up; Gas; Diarrhea; Stomach

8

Trazodone

Ultram

Valium

Vicodin

Wellbutrin

Xanax

Zaleplon

Zoloft

Cramps; Nervous; Feeling Weak; Confused; Over Excitement; Anxious.

Common side effects: Dry Mouth; Drowsiness; Dizzy; Taste Problems; Head Pain; Feel Like

Throwing Up; Throwing Up.

Infrequent side effects: Blurred Vision; Cannot Empty Bladder; Frequent Urination; Extreme

Sense of Well Being; Widening of Blood Vessels; Dry Mouth; Indigestion; Incomplete or

Infrequent Bowel Movements; "Change of Life" Signs; Drowsiness; Dizzy; Chronic Trouble

Sleeping; Excessive Sweating; Voluntary Movement Difficulty; Rash; Loss of Appetite; Head

Pain; Feel Like Throwing Up; Throwing Up; Gas; Diarrhea; Stomach Cramps; Nervous;

Feeling Weak; Confused; Over Excitement; Anxious.




Feeling Weak; Not Feeling Well. Infrequent side effects: Double Vision; Blurred Vision;

Problems with Eyesight; Dry Mouth; Incomplete or Infrequent Bowel Movements; Spasm of the Ureter or Tube Connecting Kidney to Bladder; Loss of Appetite; Head Pain; Feel Like

Throwing Up; Throwing Up; Kidney Problems Causing a Decreased Amount of Urine to be

Passed; Nervous; False Sense of Well-Being; Narcotic Addiction.

Common side effects: Dry Mouth, Sore Throat, Nausea, Vomiting, Stomach/Abdominal Pain,

Flushing, Headache, Loss of Appetite, Constipation, Trouble Sleeping, Increased Sweating,

Strange Taste in Mouth, Muscle/Joint Aches, Dizziness, or Blurred Vision.

Common side effects: Drowsiness; Inducing of a Relaxed Easy State; Slurred Speech.

Infrequent side effects: Painful Periods; Joint Pain; Pain in Arms or Legs; Low Energy;

Voluntary Movement Difficulty; Numbness and Tingling; Sexual Problems.

Common side effects: Muscle Pain; Dizzy; Head Pain; Feel Like Throwing Up. Infrequent side effects: Problems with Eyesight; Anxious; Loss of One's Own Sense of Reality or Identity;

Depression; Migraine Headache; Pink Eye; Pain in the Eye; Bronchitis; Dry Mouth;

Indigestion; Incomplete or Infrequent Bowel Movements; Painful Periods; Itching; Arthritis;

Abnormal Increase in Muscle Tone; Drowsiness; Cannot Focus Thoughts; Loss of Memory;

Fever; Involuntary Quivering; Rash; Stomach Cramps; Nervous; Numbness and Tingling;

Feeling Weak.

Common side effects: Dry Mouth; Drowsiness; Dizzy; Chronic Trouble Sleeping; Low Energy;

Excessive Sweating; Involuntary Quivering; Loss of Appetite; Weight Loss; Head Pain; Feel

Like Throwing Up; Gas; Diarrhea; Stomach Cramps; Feeling Weak. Infrequent side effects:

Feeling Restless; Blurred Vision; Problems with Eyesight; Incomplete or Infrequent Bowel

Movements; Temporary Redness of Face and Neck; Increased Hunger; Yawning; Throwing

Up; Nervous; and Anxious.

9

Dear Dr

My opinions are expressed to a degree of medical probability, unless otherwise stated.

Signature of Physician ____________________________________ Date

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Dear Dr

My opinions are expressed to a degree of medical probability, unless otherwise stated.

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Additional Comments:

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