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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