Medications/Other Treatments - Welcome | NINDS Common …



Subject ID _____________Date: / / (MM/DD/YYYY)Please list ALL medications (including prescription drugs, over the counter drugs, dietary supplements (including vitamins), herbal, homeopathic and health food preparations) taken routinely or in the last four weeks.Medication/ supplement nameDose/UnitsRoute of Administration.Prescribed dosing scheduleTaking since when?Actual usage schedule (Write “same” or write how often you are actually taking)Condition you are taking the medication forIf this medicine was prescribed for your ME/CFS, list symptoms that the medicine has improved, and list those (if any) the medicine has made worse. If medicine not prescribed for ME/CFS, write “NA” (not applicable)ExampleAspirin81 mgoral1 pill each amJan 2009Prevention of heart problemsNAExampleVitamin D1000 IUoral1 pill each pmSep 2010Prevention of osteoporosis NAExampleGabapentin300 mgoral1 pill 2x/dayJun 2012Improve nerve pain and fatigueImproved pain; thinking worse12 3 4 5 6 78910111213141516171819Examples of RoutesOf AdministrationExamples of dosing schedulesBy mouthBy suppositoryEvery night at bedtime3x a dayEvery morningBy injectionBy enemaTwice a day4x a dayEvery eveningBy skin patchAs neededOther TreatmentsTreatmentDate(s) When TreatedResult of Treatment (circle one)Dietary changesHelped/ Hurt/ No effectCognitive behavioral therapyHelped/ Hurt/ No effectGraded exercise therapyHelped/ Hurt/ No effectPacingOther (Specify):Helped/ Hurt/ No effect ................
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