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?
Comments:
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:
Please CHECK any of these you have had since your last visit:
HEENT:
Cardiac:
Respiratory:
Stomach/bowel:
Urinary:
Musculoskeletal:
Skin:
Neuro:
Endocrine:
Blood/heme:
General:
PHQ-9
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things:
Feeling down, depressed or hopeless:
Trouble falling asleep, staying asleep or sleeping too much:
Feeling tired or having little energy:
Poor appetite or overeating:
Feeling bad about yourself, or that you are a failure or have let yourself or your family down:
Trouble concentrating on things such as reading or watching television:
Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual:
Thoughts of that you would be better off dead, or of hurting yourself in some way:
If so, how likely are you to act on these thoughts?
If you checked off any problems from this list, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
