Full Name
*
Email
*
Phone
Do you feel that your medication is effectively managing your symptoms (e.g., mood, anxiety, focus)?
*
Not at all
Occasionally
Frequently
Nearly every day
Have you experienced unwanted side effects (e.g., weight gain, sleep problems, numbness, fatigue)?
*
Not at all
Occasionally
Frequently
Nearly every day
Do you feel emotionally “numb” or disconnected while on your medication?
*
Not at all
Occasionally
Frequently
Nearly every day
Have you had trouble remembering to take your medication consistently?
*
Not at all
Occasionally
Frequently
Nearly every day
Have you noticed new or worsening symptoms since starting your medication?
*
Not at all
Occasionally
Frequently
Nearly every day
Do you feel your provider has not explained your medication or options clearly?
*
Not at all
Occasionally
Frequently
Nearly every day
Do you feel unsure whether you should stay on, stop, or change your medication?
*
Not at all
Occasionally
Frequently
Nearly every day
Have you had thoughts of stopping your medication without talking to your provider?
*
Not at all
Occasionally
Frequently
Nearly every day
