Medication Evaluation Checklist

NAME:
DATE:
 
MEDICATION(S)-Confirm on EPIC
 
     
     
     
     
 
GRADE:   OTHER PERTINENT DX:
SCHOOL:  
 
     
     
     
 
 
BENEFITS:
Focus
Behavior Improved
School Performance/Grades:
Other:
SIDE EFFECTS:
1. Decrease Appetite
2. Stomach Ache
3. Headache
4. Insomnia
5. Jitteriness
6. Tics
7. Palpitations
8. Mood Swings
 
Revised June 20, 2017