Medication
Review Form

Antidepressant

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Antidepressant Medication Review Form

Required fields are marked with an asterisk (*).

Name

First

Last

Date of Birth*

Email address*

What is the name of your medication?*

Please describe below any new or ongoing side effects on your current medication *

Is the medication helping with Mood Levels?*

Is the medication helping with Anxiety Levels?*

Is the medication helping with Depression?*

Are you experiencing any of the following?*

Mood Swings

Suicidal Thoughts

Self Harm

None

Do you wish to continue with the current regime?*

Do you wish to change the dose?*

Do you want a conversation to discuss coming off the medication?*

Privacy Consent – This form collects personal and medical information about you/ We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage submitted data.

I consent to the practice collecting and storing my data from this form

Are you human?*

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