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What date is this screening form completed? (mm/dd/yyyy)
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If answer to #1 below is "yes", please proceed to #2 then STOP. If "no" proceed to #3 and complete remaining questions.
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1. Have you ever had DNA testing to see how your body handles medication?
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2.If you have had the DNA testing to see how your body handles medication, do you think the results helped your doctor treat you
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If answer to question #1 above was "yes" please stop here.
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3. Have you or a family member ever had a bad reaction to a mental health medication?
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4. Do you have any mental health diagnoses?
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4b. If you answered "yes" to current mental health diagnoses, what are they? (select all that patient self-report)
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5. In the past, did your mental health medications work well for you?
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5b. If you have never been on any psychiatric medications, please check this box.
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6. Do your current mental health medications work well for you?
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7. Are you interested in DNA testing to see which medications work best for your body?
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STAFF ONLY (if applicable)
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Why was pharmacogenetic screening tool not completed by staff?
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Patient reason for declination of pharmacogenetic testing if indicated by screening tool.
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