Medication Well-being Check
Quick review of how the patient is feeling while taking this medication.
Patient name
Date
Medication
Dose
Start date of medication
Time of last dose
Overall well-being
How do you feel today overall?
0 • Very poor
10 • Very good
Compared with before starting this medication, you feel:
Much better
Somewhat better
About the same
Somewhat worse
Much worse
Symptoms and side effects
In the last few days, have you noticed any of the following?
Nausea
Dizziness
Headache
Sleep problems
Mood changes
Other
Short description (if any of the above):
Adherence
In the last 7 days, how often did you take this medication exactly as prescribed?
Every dose
Missed 1–2 doses
Missed several doses
Stopped taking it
Notes
Patient concerns or comments
Use this space to capture any relevant clinical notes.
Clear
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