Feeling of extreme sadness Increased use of alcohol / drugs Dry mouth 􀂉 􀂉 􀂉 Feeling stressed Avoiding things Memory problems 􀂉 􀂉 􀂉 Feeling nervous or anxious Trouble performing your job Chronic weakness 􀂉 􀂉 􀂉 Feeling fearful Poor interpersonal skills Chronic pain 􀂉 􀂉 􀂉 Excessive worry Reckless behavior Muscle tension / aches 􀂉 􀂉 􀂉 Indecisiveness Trouble concentrating Numbness 􀂉 􀂉 􀂉 Depression Not getting along with friends / family Sweating / clammy hands 􀂉 􀂉 􀂉 Easily irritated Hearing voices Nerve problems 􀂉 􀂉 􀂉 Paranoid thoughts Fear of situations where escape is difficult Trembling / twitching 􀂉 􀂉 􀂉 Self-esteem problem Obsessions or compulsions Hot flashes 􀂉 􀂉 􀂉 Feeling guilty Thoughts about hurting yourself Dizziness 􀂉 􀂉 􀂉 Sudden feelings of panic Thoughts about hurting others Frequent urination 􀂉 􀂉 􀂉 Perfectionism Thoughts about killing yourself Stomach or bowel problem 􀂉 􀂉 􀂉 Change in sleeping habits Thoughts about killing others Weight changes 􀂉 􀂉 􀂉 Procrastination Suicide attempts Change in eating habits 􀂉 􀂉 􀂉 Crying spells Acting violently Self-starvation 􀂉 􀂉 􀂉 Problems with anger Intrusive thoughts Chest pain 􀂉 􀂉 􀂉 Exaggerated startle response Shortness of breath 􀂉 􀂉 Heart symptoms 􀂉 Trouble swallowing 􀂉 Change in sexual interest 􀂉 HOW LONG HAVE YOU HAD THE SYMPTOMS CHECKED ABOVE? (APPROXIMATE DATE SYMPTOMS BEGAN) ANY DETERIORATION IN JOB / SCHOOL PERFORMANCE DUE TO THE PROBLEM? ___Attendance ___Tardiness ___Decrease in productivity ___Absences Mon/Fri.’s ___Erratic Behavior ___Conflict with Supervisors ___Discipline ___None ___Conflicts with Fellow Employees CONSEQUENCES OF DETERIORATING PERFORMANCE ON WORK OR SCHOOL: On a Scale of 1-5, how would your rate your distress? (l is low, 5 is severe distress) Medical Condition You Have: (If yes check) ___Diabetes ___ High Blood Pressure ___Heart Disease ___Blood Problems ___Bone/Joint Problems ___Brain Problems ___Skin/Hair/Nail Problems ___Liver Disease ___Respiratory Problems (Breathing) ___Genital ___Kidney/Bladder ___Cancer ___Allergies ___Eyes ___Autoimmune ___Chronic Pain ___Gastrointestinal ___Head Injury Other health problems not listed above: Sleep Problems: Appetite Problems: Past Health Problems (include difficulties with developmental milestones under age 18) Medication currently using: If NONE, write your initials here
􀂉 Feeling of extreme sadness 􀂉 Increased use of alcohol / drugs 􀂉 Dry mouth 􀂉 Feeling stressed 􀂉 Avoiding things 􀂉 Memory problems 􀂉 Feeling nervous or anxious 􀂉 Trouble performing your job 􀂉 Chronic weakness 􀂉 Feeling fearful 􀂉 Poor interpersonal skills 􀂉 Chronic pain 􀂉 Excessive worry 􀂉 Reckless behavior 􀂉 Muscle tension / aches 􀂉 Indecisiveness 􀂉 Trouble concentrating 􀂉 Numbness 􀂉 Depression 􀂉 Not getting along with friends / family 􀂉 Sweating / clammy hands 􀂉 Easily irritated 􀂉 Hearing voices 􀂉 Nerve problems 􀂉 Paranoid thoughts 􀂉 Fear of situations where escape is difficult 􀂉 Trembling / twitching 􀂉 Self-esteem problem 􀂉 Obsessions or compulsions 􀂉 Hot flashes 􀂉 Feeling guilty 􀂉 Thoughts about hurting yourself 􀂉 Dizziness 􀂉 Sudden feelings of panic 􀂉 Thoughts about hurting others 􀂉 Frequent urination 􀂉 Perfectionism 􀂉 Thoughts about killing yourself 􀂉 Stomach or bowel problem 􀂉 Change in sleeping habits 􀂉 Thoughts about killing others 􀂉 Weight changes 􀂉 Procrastination 􀂉 Suicide attempts 􀂉 Change in eating habits 􀂉 Crying spells 􀂉 Acting violently 􀂉 Self-starvation 􀂉 Problems with anger 􀂉 Intrusive thoughts 􀂉 Chest pain 􀂉 Exaggerated startle response 􀂉 Shortness of breath 􀂉 Heart symptoms 􀂉 Trouble swallowing 􀂉 Change in sexual interest HOW LONG HAVE YOU HAD THE SYMPTOMS CHECKED ABOVE? (APPROXIMATE DATE SYMPTOMS BEGAN) ANY DETERIORATION IN JOB / SCHOOL PERFORMANCE DUE TO THE PROBLEM? ___Attendance ___Absences Mon/Fri.’s ___Tardiness ___Decrease in productivity ___Erratic Behavior ___Conflict with Supervisors ___Discipline ___None ___Conflicts with Fellow Employees CONSEQUENCES OF DETERIORATING PERFORMANCE ON WORK OR SCHOOL: On a Scale of 1-5, how would your rate your distress? (l is low, 5 is severe distress) Medical Condition You Have: (If yes check) ___Diabetes ___ High Blood Pressure ___Heart Disease ___Blood Problems ___Bone/Joint Problems ___Brain Problems ___Skin/Hair/Nail Problems ___Liver Disease ___Respiratory Problems (Breathing) ___Genital ___Kidney/Bladder ___Cancer ___Allergies ___Eyes ___Autoimmune ___Chronic Pain ___Gastrointestinal ___Head Injury Other health problems not listed above: Sleep Problems: Appetite Problems: Past Health Problems (include difficulties with developmental milestones under age 18) Medication currently using: If NONE, write your initials here
Adult-New-Medication-Client-Nurse.docx