Name
First Name Last Name
Please list ALL mental health medications that you are currently taking or have taken over the last THREE years. Begin with the current to past.
- Please Select the medication.
- List the Dose, Start Date, End Date, and the Result.
Mental Health Medication 1*
Medication 1 (continued)*
Mental Health Medication 2*
Medication 2 (continued)*
Mental Health Medication 3
Medication 3 (continued)
Mental Health Medication 4
Medication 4 (continued)
Mental Health Medication 5
Medication 5 (continued)
Mental Health Medication 6
Medication 6 (continued)
Please list any other medications include non-psychiatric and psychiatric medications not listed above.
Should be Empty: