Coping.us
DRUG EDUCATION/COMMUNICATION QUESTIONNAIRE (DEC-Q©)
Name: _____________________________Date: _____________________
Interviewer’s Name: ______________________Next Review Date_______________
|AREA I – Risk Evaluative |AREA II – Knowledge & Monitoring |
|Age_______Ethnicity_______________ |Do you know your diagnosis and treatment plan? |
|Weight (#’s, + or -)_________________ |Do you know the dose of your drug? |
|Renal or Liver Disease (Circle) |Shape, size, color, smell, & taste? |
|↑Caffeine ≥ 250 mg_________________ |Do you know what side effects to report immediately? |
|Hypo/Hyperthyroid Screen (y/n) _______ |What do you do if you miss a dose? |
|↑Smoker (y/n) _____↑Alcohol (y/n) _____ |Where do you get your medication info? |
|↑Smokeless Tobacco_________ |Does anyone help you with your meds? |
|Following Drugs Prescribed: (circle yes/no) |Use any OTC or household remedies? |
|yes no: Neuroleptics/SDAs (AIMS) |List: |
|yes no: Insulin/warfarin | |
|yes no: Lithium/↓valproate/↑carbamazepine | |
|yes no: Street Drugs: ______________ | |
|Interaction Scan (+ OTC) via Medscape or WebMD: | |
|Level of Patient/Therapist Exchange_____ | |
|(1 Easy - 3 Moderate - 5 Difficult) | |
|AREA III – Communication |AREA IV – Creative Non-Adherence |
|Why are you taking these meds? |Stopped taking any drugs on your own (drug holiday)? |
|How do you take your meds? |Are you doing anything to make meds last longer/go further |
|Do they work for you? |(splitting, doubling, grapefruit juice, borrowing, trading)? |
|When was the last time you discussed your meds with your provider and|Are you afraid of any of your meds? |
|have your meds changed? |Any meds you’re taking now that’s caused problems before? |
|Do you feel comfortable discussing your medications and treatment |Anything about your sex life you’d like |
|with your providers? |to change? |
|For Females Only: Pregnant or planning a |Do you believe you’re in control of your treatment plan? |
|pregnancy? | |
|For Males Only: Desire child/additional? | |
[Legend: ↑↓Potential CYP Induce/Inhibit]. Advisory: Use in conjunction with thorough drug history; for patient
education purposes only. Attach note for actions/corrections taken. ©Perry W. Buffington, Ph.D.,
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