* = Required Information
Psychiatric Evaluation/Psychotropic Medication Evaluation
Individual
*
Date
Date of Birth
*
Name of Staff attending appointment
*
Prescriber Name
*
Current Diagnoses
*
Current Medication Administration Record attached
Yes
No
If no, current medications and doses must be listed below:
Problems with Medication Administration since last appointment?
PRN Medication Use
Side Effects Noted
Current Target Symptoms and Behaviors Tracked
Increased
Decreased
Stable
Increased
Decreased
Stable
Increased
Decreased
Stable
Increased
Decreased
Stable
Increased
Decreased
Stable
Environmental Factors that could have an effect on the above symptoms
***Below To Be Completed By Prescriber***
Summary of Current Status
(Print clearly OR attach electronic appointment summary)
Other Monitoring Requested of Residential Provider
Additional Symptoms Prescriber Would Like to Have Tracked
New Orders
(Print clearly OR attach electronic appointment summary)
MEDICATION CHANGES
Medication Increased?
Yes
No
Name of med(s), dose/time
Medication Decreased?
Yes
No
Name of med(s), dose/time
Medication Added?
Yes
No
Name of med(s), dose/time
Medication Discontinued?
Yes
No
Name of med(s), dose/time
Please Note:
1.Medications will be continued until they are reviewed at the next appointment unless start and stop dates are indicated.
2.Symptoms will be monitored and reported at scheduled appointments unless otherwise requested.
3.Please attach prescriptions for all medication changes noted above or communicate them directly with the pharmacy.
4.Unless otherwise specified, you will be notified if the individual misses or refuses more than two consecutive doses of medication.
5.Your signature below indicates that you have reviewed the above information with the individual and the staff.
Next Appointment Date and Time
Prescriber Name Clearly Printed
Date
Submit