Drug Assessment Journal Form
Record and evaluate your drug assessment experiences. Keep your entries clear, focused, and concise.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Drug Name
*
Dosage / Form (e.g., 10mg tablet, 5ml liquid)
*
Method of Administration
*
Please Select
Oral
Topical
Injection
Inhalation
Other
Purpose of Use
Perceived Effectiveness
*
1
2
3
4
5
Side Effects Experienced
None
Nausea
Headache
Drowsiness
Dry mouth
Other
Overall Experience
*
Very Negative
1
2
3
4
5
6
Very Positive
7
1 is Very Negative, 7 is Very Positive
Would you use this drug again for the same purpose?
Yes
No
Unsure
Additional Notes or Observations
Submit Assessment
Should be Empty: