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 *

How well do you feel the medication is helping with mood and anxiety levels? (for example- mood swings/ suicidal thoughts/ self-harm/ none)*

How do you manage with day to day activities ? Specifically, Please describe, in the last few months, how much does your condition currently affect your work and home life*

Do you wish to continue with the current regime, change dose or thinking you are ready to come 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?*

This field should be left blank

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