MEDICATION MANAGEMENT FORM

MEDICATION MANAGEMENT FORM
OUTPATIENT MENTAL HEALTH CLINIC
236 W ALLEGHENY AVE PHILADELPHIA, PA 19133-3629
215-989-1771
admin@alliedcomfortncare.com
PATIENT INFORMATION
Patient Name:
Date of Birth:

MonthDayYear
Date
Date:

MonthDayYear
Date
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Primary Diagnosis / Reason for Treatment:
1. CURRENT MEDICATIONS
List all current medications including prescription, over-the-counter, vitamins, and supplements.
Medication Name
1
2
3
Dose
1
2
3
Frequency
1
2
3
Prescriber
1
2
3
Reason for Taking
1
2
3
Start Date
1
2
3
2. ALLERGIES & ADVERSE REACTIONS
List any medication allergies or adverse reactions.
Medication
1
2
3
Reaction
1
2
3
3. PHARMACY INFORMATION
Pharmacy Name:
Address:
Phone Number:
Format: (000) 000-0000.
4. MEDICAL HISTORY
Check all that apply.
Medical History Conditions

Other
Please list any other medical conditions:
5. SUBSTANCE USE
Check all that apply.
Substance Use
Additional Information (optional):
6. PAST PSYCHIATRIC MEDICATION TRIALS
List any past psychiatric medications you have taken.
Medication Name
1
2
Dose
1
2
Reason for Discontinuation
1
2
Side Effects
1
2
Effective (Yes/No)
1
2
7. PATIENT UNDERSTANDING & CONSENT
I understand the following regarding medication management services:
- The purpose of medication is to reduce symptoms and improve functioning.
- There are potential benefits and risks associated with all medications.
- It may take time to find the most effective medication and dose.
- I should not stop or change my medication without consulting my provider.
- I will inform my provider about side effects or concerns.
- I will keep scheduled appointments and follow treatment recommendations.
- I authorize Allied Comfort & Care to communicate my pharmacy and other healthcare providers as needed for safe and effective care.
I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.
I consent to receive medication management services from Allied Comfort & Care.
POTENTIAL SIDE EFFECTS
Side effects vary depending on the medication.
Common side effects may include:
- Nausea
- Drowsiness
- Dizziness
- Dry mouth
- Weight changes
- Sexual dysfunction
- Mood or behavioral changes
- Other (varies by medication)
Report any side effects to your provider immediately.
8. FOLLOW-UP PLAN
Next Appointment Date:

MonthDayYear
Date
Monitoring Plan:
Lab Tests / Monitoring (if applicable):
9. EMERGENCY CONTACT
Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Patient / Guardian Signature:
Date:

MonthDayYear
Date
Provider Signature:
Date:

MonthDayYear
Date
Compassionate Care. Empowering Wellness. Supporting Recovery.
CRISIS RESOURCES: Emergency: 911 | Suicide & Crisis Lifeline: 988 | Philadelphia Crisis Line: 215-685-6440
Should be Empty:

MEDICATION MANAGEMENT FORM

OUTPATIENT MENTAL HEALTH CLINIC

PATIENT INFORMATION

1. CURRENT MEDICATIONS

Medication Name

Dose

Frequency

Prescriber

Reason for Taking

Start Date

2. ALLERGIES & ADVERSE REACTIONS

Medication

Reaction

3. PHARMACY INFORMATION

4. MEDICAL HISTORY

5. SUBSTANCE USE

6. PAST PSYCHIATRIC MEDICATION TRIALS

Medication Name

Dose

Reason for Discontinuation

Side Effects

Effective (Yes/No)

7. PATIENT UNDERSTANDING & CONSENT

8. FOLLOW-UP PLAN

9. EMERGENCY CONTACT