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PSYCHIATRIC MEDICATION HISTORY
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Select and enter details for any medications you have taken
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Selective Serotonergic Reuptake Inhibitors
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Fluoxetine (Prozac)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Paroxetine (Paxil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Sertraline (Zoloft)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Citalopram (Celexa)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Escitalopram (Lexapro)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Fluvoxamine (Luvox)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Serotonin and Norepinephrine Reuptake Inhibitors
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Duloxetine (Cymbalta)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Venlafaxine (Effexor)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Desvenlafaxine (Pristiq)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Milnacipram (Savella)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Levomilnacipram (Fetzima)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Other Antidepressants
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Vilazodone (Viibryd)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Vorteoxetine (Trintellix)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Bupropion (Wellbutrin)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Mirtazapine (Remeron)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Nefazodone (Serzone)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Trazodone (Desyrel)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Agomelatine (Valdoxan)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Tricyclic Antidepressants
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Clomipramine (Anafranil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Imipramine (Tofranil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Amitriptyline (Elavil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Desipramine (Noripramin)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Nortriptyline (Pamelor)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Trimipramine (Surmontil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Amoxapine (Asendin)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Maprotiline (Ludiomil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Doxepin (Sinequan)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Protriptyline (Vivactil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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MAO Inhibitors
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Phenelzine (Nardil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Tranylcypromine (Parnate)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Isocarboxazid (Marplan)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Selegiline (Emsam patch)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Atypical Antipsychotics-SGA
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Aripiprazole (Abilify)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Quetiapine (Seroquel)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Olanzapine (Zyprexa)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Risperidone (Risperdal)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Paliperidone (Invega)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Ziprasidone (Geodon)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Clozapine (Clozaril)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Asanapine (Saphris)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Lurasidone (Latuda)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Brexpiprazole (Rexulti)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Cariprazine (Vraylar):
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Lumateperone (Caplyta)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Antipsychotics
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Haloperidol (Haldol)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Thioridazine (Mellaril)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Chlorpromazine-‐Thorazine
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Perphenazine (Trilafon)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Trifluoperazine (Stelazine)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Loxapine
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Mood Stabilizers
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Lithium salts (Lithium)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Valproic acid / Depakote
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Lamotrigine (Lamictal)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Carbamazepine (Tegretol)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Oxcarbazepine (Trileptal)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Levetiracetam (Keppra)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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ADHD/Wakefulness
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Amphetamines (Adderall)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Dexamphetamine -Dexedrine
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Lisdexamfetamine-‐Vyvanse
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Methylphenidate (Ritalin/Concerta/Metadate/Daytrana)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Modafinil (Provigil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Armodafinil (Nuvigil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Atomoxetine (Strattera)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Guanfacine (Intuniv) or IR form
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Other Agents
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Buspirone (Buspar)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Liothyronine (Cytomel)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Gabapentin (Neurontin)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Pramipexole (Mirapex)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Omega 3 (Fish oil)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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L-Methylfolate (Deplin, EnLyte, ENL, EmBrace, ENL-D))
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Folate – Folic acid
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Topiramate (Topomax)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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SAMe
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Roprinole (Requip)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Inositol
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Varenicline (Chantix)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Testosterone/Androge
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Estrogen
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Vistaril or Hydroxyzine
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Benzodiazepines
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Clonazepam (Klonopin)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Alprazolam (Xanax)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Lorazepam (Ativan)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Diazepam (Valium)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Temazepam (Restoril)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Oxazepam (Serax)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Chlordiazepoxide (Librium)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Sleep Medications
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Zolpidem (Ambien)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
|
Please describe any side effects
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Zaleplon (Sonata)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
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Please describe any side effects
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Eszopliclone (Lunesta)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
|
Please describe any side effects
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Ramelteon (Rozerem)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
|
Please describe any side effects
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Doxepin (Silenor)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
|
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Did It help?
|
Please describe any side effects
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Belsomra (suvorexant)
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Last taken Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
|
|
Did It help?
|
Please describe any side effects
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|
Other Psychiatric Treatments:
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Lithium Orotate
|
Highest Dose/Level
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Taken as directed for >6 Weeks
|
Please describe any side effects
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Did It help?
|
Last Received/Used Month/Year
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NAC
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Last Received/Used Month/Year
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Taken as directed for >6 Weeks
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Highest Dose/Level
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Did It help?
|
Side effects? Please describe
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ECT
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Last Received/Used Month/Year
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Types of Stimulation
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Number of Sessions
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Did It help?
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Side effects? Please describe
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TMS
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Last Received/Used Month/Year
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Types of Stimulation
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Number of Sessions
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Did It help?
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Side effects? Please describe
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t-DCS
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Last Received/Used Month/Year
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Types of Stimulation
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Number of Sessions
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Did It help?
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Side effects? Please describe
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VNS
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Last Received/Used Month/Year
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Number of Sessions
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Did It help?
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Side effects? Please describe
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DBS
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Last Received/Used Month/Year
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Number of Sessions
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Did It help?
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Side effects? Please describe
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Ketamine Infusion or esketamine (Spravato)
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Last Received/Used Month/Year
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Number of Sessions
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Did It help?
|
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Side effects? Please describe
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Light Therapy
|
Last Received/Used Month/Year
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|
Number of Sessions
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Did It help?
|
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Side effects? Please describe
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