Learn more!
Home
(current)
About Us
(current)
Office Info
(current)
Office Forms
(current)
Lactation
(current)
Contact Us
(current)
Medication Evaluation Checklist
NAME:
DATE:
MEDICATION(S)-Confirm on EPIC
Daily
Just School Day
Daily
Just School Day
Daily
Just School Day
Daily
Just School Day
GRADE:
OTHER PERTINENT DX:
SCHOOL:
IEP
Depression
504
Anxiety
Extra help
Autism
Tutor
Counseling
Yes
No
Honors/A.P.
Other
BENEFITS:
Focus
Yes
Somewhat
No
Behavior Improved
Yes
Somewhat
No
School Performance/Grades:
Other:
SIDE EFFECTS:
1.
Decrease Appetite
Yes
No
2.
Stomach Ache
Yes
No
3.
Headache
Yes
No
4.
Insomnia
Yes
No
5.
Jitteriness
Yes
No
6.
Tics
Yes
No
7.
Palpitations
Yes
No
8.
Mood Swings
Yes
No
Revised June 20, 2017