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BEHAVIORAL HEALTH: TEAM REVIEW OF PSYCHOTROPIC MEDICATIONPART ONE: HEALTH SERVICES REPORT(To be completed by agency/residential staff (e.g. nurse, program specialist) prior to psychotropic medication)INDIVIDUAL: FORMTEXT ?????DATE-PSYCHOTROPIC MED REVIEW: FORMTEXT ?????ADDRESS: FORMTEXT ?????PREVIOUS REVIEW: FORMTEXT ?????DATE OF BIRTH: FORMTEXT ?????PHYSICIAN’S NAME: FORMTEXT ?????(Insert Agency Name) CONTACT: FORMTEXT ?????OFFICE ADDRESS: FORMTEXT ?????CONTACT PHONE: FORMTEXT ?????OFFICE PHONE: FORMTEXT ?????CURRENT MEDICATIONS (Please list all medications, including over-the-counter, dietary supplements, etc. Attach additional pages if necessary. Include the individual’s name and date of review on every page.)MEDICATION NAMEDOSAGEFREQUENCYReason for Administration FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ARE THERE ALLERGIES OR CONTRA-INDICATED MEDICATIONS? FORMCHECKBOX NO FORMCHECKBOX YESIf “YES,” Specify and describe all symptoms:HAS THIS DIAGNOSIS CHANGED? SEE PAGE 3and check if updated: DIAGNOSIS (5-Axis Diagnosis from a physician, as documented in medical records)TARGET SYMPTOMS (BEHAVIORAL DESCRIPTION) Target Symptoms listed here must match those listed on Part 2AXIS I(MH Diagnosis) FORMTEXT ????? FORMTEXT ?????AXIS I (2) FORMTEXT ????? FORMTEXT ?????AXIS II(MR Diagnosis) FORMTEXT ????? FORMTEXT ?????AXIS II (Personality Disorder) FORMTEXT ?????AXIS III(All Medical Diagnoses) FORMTEXT ?????AXIS IV (Psychosocial Stressors): as documented by physician/medical records. Notify physician if new issues/changes. Check all that apply: FORMCHECKBOX Problem with primary support group FORMCHECKBOX Problems with access to health care services FORMCHECKBOX Housing problems FORMCHECKBOX Problems related to the social environment FORMCHECKBOX Occupational problems FORMCHECKBOX Educational problems FORMCHECKBOX Problems related to the judicial system FORMCHECKBOX Other psychosocial/environmental problems FORMCHECKBOX Economic Problems_______________________________________________________________________________AXIS V (Global Assessment of Functioning/GAF) Score (0-100) FORMTEXT ????? (Score provided by physician per DSM scale)________________________________________________________________________________Last Tardive Dyskinesia Screening (e.g. AIMS test): (Include date and result – required every 6 months)Score: FORMTEXT ?????Date: FORMTEXT ????? ___________________________________________________________________________________CURRENT HEALTH STATUS/MEDICAL ISSUES OF NOTE (Attach significant lab and diagnostic study results):CHECK all items that were an issue since the last psychotropic medication review. Add comments whenever possible. FORMCHECKBOX appetite +/- FORMCHECKBOX constipation FORMCHECKBOX dry mouth FORMCHECKBOX nausea/vomiting FORMCHECKBOX swelling FORMCHECKBOX alcohol use FORMCHECKBOX bruising FORMCHECKBOX cough FORMCHECKBOX incontinence FORMCHECKBOX seizures FORMCHECKBOX weight +/- FORMCHECKBOX nicotine use FORMCHECKBOX congestion FORMCHECKBOX diarrhea FORMCHECKBOX menstrual change FORMCHECKBOX thirst FORMCHECKBOX pain FORMCHECKBOX caffeine useCOMMENTS OR SYMPTOMS NOT INCLUDED IN ABOVE LIST: (Please describe) FORMCHECKBOX other drug use FORMTEXT ?????Printed name and signature(s) indicating prior psychotropic medication review reports were reviewed in preparing this pleted by: (Printed Name and Signature):Title: Date Signed:Agency Nurse Review: (Printed Name & Signature):Title:Date Signed: ................
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