Past Psychiatric Medication History

1
Patient Name* This field is required.
First Name
Last Name
2
Patient Date of Birth* This field is required.
Date
Month
Day
Year
3
Have you every tried any medication for a mental health condition?
YESNO
4
Serotonin Reuptake Inhibitors (SSRIs)Please check one medication per line
5
Trycyclic Antidepressants (TCAs)Please check one medication per line
6
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)Please check one medication per line
7
Monoamine Oxidase InhibitorsPlease check one medication per line-these medications usually require diet modification
8
Other AntidepressantsPlease check one medication per line
9
First Generation Antipsychotics
10
Older Second Generation Antipsychotics
11
Newer Second Generation Antipsychotics
12
Anticonvulsant Mood Stabilizers and Lithium
13
Non-benzodiazepines for anxiety
14
Benzodiazepines
15
Amphetamines
16
Methylphenidate
17
Non-stimulant ADHD medications
18
”Z” Medications for Sleep
19
Other Sleep Medications
20
Other Medications Used in Psychiatry
21
What treatments outside of medication have you tried?
22
Please list here any other medications or treatment modalities that you have used for psychiatric treatment
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Large
Normal
Small
Ok
Ok
Should be Empty: