HTML Preview Medication Treatment Checklist page number 1.
MEDICATION TREATMENT EMERGENT EFFECTS CHECKLIST
Client’s name: _________________________________________ Date of assessment: ____/_____/____ Assessor _____
Drug(s) and dosage: _____________________________________________________________________________________
Instructions: Fill out before initial medication use, and at least once a month during, and for 3 months after, medication use. Inquire
about the presence of each event over the past week. Causation by treatment need not be suspected or established. If present, score as 1
(mild), 2 (moderate), or 3 (severe). If not present, leave blank. For items listing different or opposite events (e.g., “increased” or “decreased”
appetite, circle the appropriate one.)
Psychological
1, 2, 3
Gastrointestinal
1, 2, 3
1. Agitation (restless, nervous, hyperactive)
43. Increased or Decreased appetite
2. Confusion, cognitive difficulties
44. Weight Gain or Loss
3. Memory problems, forgetfulness
45. Abdominal pain or cramps, Stomach bloating
4. Irritability (easily upset, angry)
46. Increased thirst
5. Impulsivity
47. Nausea, vomiting
6. Trouble concentrating or paying attention
48. Diarrhea
7. Insomnia, trouble falling or staying asleep
49. Constipation
8. Hypersomnia, trouble waking up
50. High blood sugar
9. Crying spells, sadness
51. Other:
10. Anxiety, tension, Panic (racing heart, breathless)
Musculoskeletal/Neurological
11. Lethargy, apathy, sedation, drowsiness
52. Disequilibrium, unsteady gait, poor coordination
12. Nightmares, intense dreaming
53. Spinning, swaying, lightheaded
13. Feeling detached or unreal
54. Weakness, fatigue
14. Elevated mood (feeling high/euphoric/giddy)
55. Numbness, burning or tingling sensations
15. Mania/mood swings
56. Slowed movements, sluggishness, muscle rigidity
16. Hearing voices, seeing things
57. Muscle cramps, stiffness, twitches, jerks, spasms
17. Aggressivity, hostility
58. Restlessness, pacing, rocking, hopping, can’t sit still
18. Homicidal thoughts or urges
59. Tremor (slight shaking/trembling of limbs or muscles)
19. Self-harm (cutting, piercing)
60. Any other abnormal involuntary movements anywhere
20. Suicidal thoughts or urges
61. Other:
21. Suicide attempts
Skin
22. Other:
62. Increased or Reduced sweating
Head/Face
63. Increased sensitivity to sun
23. Headache
64. Chills or Feelings of warmth
24. Blurred or Double vision
65. Rash, hives / Dry skin, crusty
25. Sore eyes
66. Acne
26. Ringing or other noises in the ears
67. Easy bruising
27. Abnormal smells or tastes
68. Pale, yellowing skin
28. Electric zap-like sensations in the head
69. Hair loss or Abnormal hair growth
29. Drooling, excessive saliva
70. Other:
30. Slurred speech
Genito-Urinary
31. Tics, eye blinks, or grimaces
71. Menstrual disturbances (absent or irregular periods)
32. Abnormal movements of mouth, lips, tongue
72. Difficulty urinating / Increased urination
33. Expressionless, “zombie” look
73. Enuresis, night bedwetting
34. Other:
74. Difficulties with orgasm
Nose/Throat/Chest
75. Erectile dysfunction, impotence
35. Runny nose/ Stuffed nose
76. High or Low sexual desire / activity (libido)
36. Fever
77. Other:
37. Flu-like aches and pains
Cardiovascular
38. Sore throat/Difficulty swallowing
78. High blood pressure
39. Labored breathing
79. Arrythmia (irregular heartbeat)
40. Chest pain
80. Tachychardia (abnormally fast hearbeat)
41. Breast swelling or discharge
81. Cardiac arrest
42. Other:
82. Other:
Adapted from: Kalachnik JE. Measuring side effects of psychopharmacologic medication.
Mental Retardation & Developm. Disability Research
Review
1999: 4, 349-359; 2) Rosenbaum et al. SSRI discontinuation syndrome,
Biological Psychiatry
1998
: 44
, 77-87. (3) Bezchlibnyk-Butler &
Jeffries, 2005,
Clinical handbook of psychotropic drugs
(15th rev. ed). Seattle: Hogrefe.
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