1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Med Management Follow up visit

Name: Date of Birth: Date:

Are you taking medications as prescribed?  YesNo

How often do you miss a dose?

Time you go to bed:

Time you fall asleep:

How many times do you wake in the middle of the night?

Time you get up for the day?

Naps:

Please CHECK any of these you have had since your last visit:

 Alcohol Cannabis Tobacco Caffeine Meth/cocaine Pain pills/heroin Other

Please CHECK any of these you have had since your last visit:

     HEENT:  headaches dry mouth blurred vision grinding/clenching teeth

     Cardiac:  heart palpitations racing heart chest pain

     Respiratory:  shortness of breath coughing wheezing

     Stomach/bowel:  nausea vomiting diarrhea constipation abdominal pain

     Urinary:  leakage hard to start stream burning frequent urge excessive urination

     Musculoskeletal:  joint pain muscle pain

     Skin:  rash itching excessive sweating acne hair loss excessive hair growth

     Neuro:  tremor/shakiness dizziness unsteadiness falls numbness/tingling slurred speech movements not done on purpose

     Endocrine:  change in sexual function change in menstrual cycle feeling too hot or too cold excessive thirst breast enlargement breast discharge

     Blood/heme:  easy bruising unusual bleeding

     General:  fever change in weight change in appetite