Medication Switch Risk Assessment Form
Evaluate the safety and readiness for a medication change using this structured risk assessment.
Current medication class/type
*
Please Select
Antidepressant
Antihypertensive
Antipsychotic
Antidiabetic
Antiepileptic
Other
What is the primary reason for considering a medication switch?
*
Lack of efficacy
Adverse effects
Drug interactions
Patient preference
Cost/insurance
Other
Has the patient experienced any adverse reactions to previous medications?
*
Yes
No
Unknown
Select all relevant comorbidities that may increase risk during a medication switch:
*
Renal impairment
Liver impairment
Cardiovascular disease
Seizure disorder
Diabetes
None
Other
Current symptom stability
*
1
2
3
4
5
How confident is the patient in understanding the reason for the switch?
*
1
2
3
4
5
Which of the following monitoring plans are in place for the switch?
*
Regular follow-up visits
Laboratory monitoring
Symptom tracking
Emergency plan provided
None
Support system availability (e.g., family, caregiver, case manager)
*
Strong support
Some support
Minimal or no support
Please rate the overall risk of switching medications for this patient.
*
Very Low Risk
1
2
3
4
Very High Risk
5
1 is Very Low Risk, 5 is Very High Risk
Submit Assessment
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