Pg. 1 of 2
St. Clair County Community Mental Health Authority
Pre-Appointment Medication Review Questionnaire
Name: ___________________________________ Birthdate: _________Case #: _________ Date: _________
Who is your primary care provider?_____________________________________________________________
List your current medications from all other providers:
______________________________ _____________________________ ___________________________
______________________________
_____________________________ ___________________________
______________________________
_____________________________ ___________________________
Are you taking any non-prescription or over-the-counter preparations, e.g., herbs, supplements, vitamins, etc?
______________________________ _____________________________ ___________________________
______________________________
_____________________________ ___________________________
Are you having any side effects from the medications we have prescribed for you? If so, please list them:
______________________________ _____________________________ ___________________________
______________________________
_____________________________ ___________________________
Have you been thinking of harming yourself?
If yes, are you thinking of ways you could do it?
No
No
Yes
Yes If yes, what are they? _________________
_________________________________________________________________________________________
Do you intend to harm yourself after you leave here today?
No
Yes
Do you intend to harm another person after you leave here today?
No
Yes
During the last 7 days, if you had any of the following symptoms, please rate them from 0 to 10 (10 is the worst):
Depression: ____________________________________ Anxiety: _________________________________
Irritability (short fuse, grouchy, angry): ______________ Hopelessness: _____________________________
Are you having any sleeping difficulties?
No
Yes If yes, please explain: _______________________
How long does it take for you to fall asleep? __________ Do you sleep through the night?
No
Yes
How many hours do you sleep at night? _________ Do you take any naps during the daytime?
No
Yes
FOR FEMALES ONLY:
Are you pregnant?
Yes
No
If no, when did your last menstrual period start? ___________________
Do you take any birth control pills?
No
Yes If yes, what kind? ______________________________
Are you on Depo Provera injections?
No
Yes Do you have an implant for birth control?
No
Yes
No
No
Yes
Did you have Uterine Ablation (Novasure)?
Yes
Did you have a hysterectomy?
Form #315, Pg. 1 of 2
Rev. 6/13
\\Fileshare001\web_storage\Forms\Clinical\315 Pre-Appointment Medication Review Questionnaire (Handwritten).doc
Pg. 2 of 2
St. Clair County Community Mental Health Authority
Pre-Appointment Medication Review Questionnaire
Name: __________________________________ Birthdate: _________Case #: _________ Date: __________
REVIEW OF SYMPTOMS
General:
Weight loss?
No
Yes How much? ______
Fever?
No
Yes Temperature: ______
Decrease in energy?
Yes
No
Decrease in appetite?
Yes
No
Night sweats?
Yes
No
Head, Eyes, Ears, Nose, Throat:
Sinus infection/pain?
Ear pain?
Change in hearing?
Eye pain?
Change in vision?
Nasal discharge?
Throat pain?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Cardiac:
Chest pain?
Shortness of breath?
Shortness of breath at night?
Decrease in ability to exert oneself?
Yes
Yes
Yes
Yes
No
No
No
No
Respiratory:
Blood in sputum?
Cough or change in cough?
Shortness of breath lying down?
Mucus production with cough?
Yes
Yes
Yes
Yes
No
No
No
No
Gastrointestinal:
Difficulty swallowing food?
Pain with swallowing food?
Indigestion?
Nausea?
Vomiting?
Diarrhea?
Abdominal bloating?
Black stools?
Blood from the rectum?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Genitourinary:
Burning with urination?
Blood in urine?
Increase in need to urinate?
Increase in need to urinate at night?
Yes
Yes
Yes
Yes
No
No
No
No
Skin:
Infections?
Ulcers?
Rashes?
Yes
Yes
Yes
No
No
No
Musculoskeletal:
Arthritis?
Back pain?
Neck pain?
Bone pain?
Muscle soreness?
Recent trauma or fractures?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Neurological:
Headaches?
Recent change in vision?
Recent change in hearing?
Change in ability to feel things?
Painful sensations?
Decrease in muscle strength?
Decrease in ability to walk/ambulate?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Hematologic:
Bleeding from nose, rectum or any
other site in the body?
Yes
No
Extremities:
Redness of a limb?
Swelling of a limb?
Discoloration of a limb?
Yes
Yes
Yes
No
No
No
Other Comments: __________________________
__________________________________________
__________________________________________
FOR OFFICE USE ONLY
Blood Pressure
Height
Pulse
Weight
Rhythm
BMI
Females Only:
Pregnant
LMP
Menopausal/Hysterectomy/On Depot
Provera Injec./Implant/Uterine Ablation
Reviewed By:
_________________________________________________________________________________
Form #315, Pg. 2 of 2
Rev. 6/13
\\Fileshare001\web_storage\Forms\Clinical\315 Pre-Appointment Medication Review Questionnaire (Handwritten).doc
Date: _____________________________