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?
Please CHECK any of these you have had since your last visit:
Alcohol Cannabis Tobacco Caffeine Meth/cocaine Pain pills/heroin Other
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
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Document Name: Med Management Follow up visit
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