Whenever you have a change in medications or therapies, your moods will improve, worsen, or stay about the same. Documenting how you feel can be a valuable tool in helping you team up with your doctor and therapist to obtain the right combination of medications and therapy. Use the following form to record the most recent change in your treatment plan and in how you feel since the change. (Or download the form as a Word Document.)
Date of treatment modification: ___________________________
Description of medication change or change in therapy:
______________________________________________________
How do you feel since the treatment modification?
__ Greatly improved
__ Somewhat improved
__ About the same
__ Somewhat worse
__ Much worse
What improvements, if any, have you noticed?
____________________________________________________
Note any problems you experienced since the change:
__ Inability to concentrate or focus on tasks
__ Sadness/crying
__ Aches/pains
__ Sleeping too much
__ Sleeping too little or inability to sleep
__ Irritability or anger
__ Worried or anxious
__ Fatigue – lack of energy
__ Feeling overwhelmed at work or home
__ Thoughts of death or suicide
__ Increased use of alcohol or other substances
__ Increased risk taking
__ Other (describe): _______________________________________
If you changed medications, did you experience any of the following common side effects?
__ Weight gain or loss: ( __________ lbs)
__ Confusion
__ Loss of memory
__ Constipation
__ Diarrhea
__ Dizziness
__ Nausea
__ Sexual difficulties
__ Shortness of breath
__ Dry mouth
__ Night sweats
__ Rash
__ Other (describe): ________________________________
Are you adhering to your treatment plan?
__ Yes
__ No
__ Sort of (explain): _____________________________________
Has anyone commented on your mood? If so, what did they say?
___________________________________________________________
___________________________________________________________
___________________________________________________________
What changes would you need to experience to consider yourself “feeling good?”
___________________________________________________________
___________________________________________________________
___________________________________________________________
Jot down any questions you have for your doctor or therapist:
Question 1: __________________________________________________
Answer: ____________________________________________________
Question 2: __________________________________________________
Answer: ____________________________________________________
Question 3: __________________________________________________
Answer: ____________________________________________________
Tip: Make a copy of this form for your doctor, so he or she can keep a copy in your file for future reference. This can help you and your doctor avoid trying a new medication that you already tried and had problems with in the past.
Important: Always consult your doctor before you stop taking a prescribed medication. If a medication is producing undesirable side effects, your doctor can often recommend ways to reduce or eliminate those side effects without having to discontinue the medication. For more about dealing with undesirable side effects, check out our post, “Managing Bipolar Medication Side Effects.”
Trackbacks/Pingbacks