Psychiatric Medication History Assessment | Medication Effectiveness & Side Effects Review 

This comprehensive medication history assessment is designed to help identify how current and previous medications may be affecting mood, anxiety, attention, sleep, energy, cognition, and overall functioning. Many individuals have tried multiple medications over time and may not remember exact dosages or dates. That's okay. Please do the best you can. Approximate information is often sufficient to help identify patterns of effectiveness, side effects, medication interactions, and treatment responses. The goal is to provide your therapist and healthcare providers with a clear overview of your medication history to support more informed treatment planning.

Medication History & Effectiveness Assessment

Comprehensive Psychiatric Medication Review

Double Board Certified Counseling Services, Inc.

Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ASDCS, NATC, CCTP, CCTP II, ADHD-CCSP, C-DBT, C-PD

Provider:
Double Board Certified Counseling Services, Inc.
Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ASDCS, NATC, CCTP, CCTP II, ADHD-CCSP, C-DBT, C-PD
Email completed assessment to: [email protected]

Directions

Please complete this form as best you can. Exact medication names, dates, and dosages are helpful, but they do not have to be perfect. Approximate information is often enough to identify patterns in medication effectiveness, side effects, mood changes, anxiety, fatigue, sleep, alertness, and attention.

After completing the form, click Generate Clinical Summary, then choose Print / Save as PDF or Download Completed HTML. Email the completed file or PDF to [email protected]. The email button may open your email app, but you may still need to attach the saved file manually.

Client Information

Client Name

Date

Date of Birth / Age

Current Prescriber(s)

Primary Care Provider

Pharmacy

Primary symptoms or medication concerns you want reviewed

Current Medications

Include psychiatric medications, ADHD medications, sleep medications, hormones, pain medications, supplements, GLP-1 medications, thyroid medications, or any medication that may affect mood, sleep, energy, appetite, alertness, anxiety, or concentration.

#	Medication Name	Dosage	How Long Taking?	Reason Prescribed	Does It Work?	Helpful 0–10	Side Effects	Missed Doses?	Notes

Current Side Effects Checklist

Check any side effects you currently experience or suspect may be medication-related.

Fatigue Sleepiness or sedation Brain fog Memory problems Weight gain Weight loss Increased anxiety Increased depression Irritability Emotional blunting Sexual side effects Dry mouth Constipation Dizziness Headaches Nausea or GI upset Tremor Sweating Insomnia Restlessness / akathisia Increased appetite Reduced appetite Elevated heart rate Elevated blood pressure Other

Additional side effect details

Previous Medications

Please do your best. Exact dates, dosages, and medication names are not required. Approximate information is still clinically useful.

#	Medication Name	Approx. Dosage	Approx. Dates / How Long?	Reason Prescribed	Helpful?	Why Stopped?	Side Effects	Withdrawal / Rebound?	Notes

Medication Trial Patterns

Which medication helped the most?

Which medication helped the least or did not work?

Which medication caused the most side effects?

Which medication was hardest to stop or caused withdrawal/rebound?

Has any medication lost effectiveness over time?

What symptoms remain untreated?

Medication Category Review

ADHD / Stimulant / Non-Stimulant Medication History

Adderall Vyvanse Concerta Ritalin Focalin Azstarys Strattera / atomoxetine Qelbree / viloxazine Guanfacine / clonidine

Most effective ADHD medication, least effective, side effects, rebound symptoms, or fatigue/alertness effects

Antidepressant Medication History

SSRIs SNRIs Wellbutrin / bupropion Tricyclics MAOIs Trazodone Mirtazapine

Most helpful antidepressant, least helpful, emotional blunting, fatigue, sleep effects, or withdrawal symptoms

Mood Stabilizer / Antipsychotic History

Lamictal / lamotrigine Lithium Depakote / valproate Seroquel / quetiapine Abilify / aripiprazole Risperdal / risperidone Latuda / lurasidone Caplyta / lumateperone

Benefits, sedation, weight gain, restlessness/akathisia, mood stability, or emotional effects

Anxiety / Sleep Medication History

Benzodiazepines Buspirone Hydroxyzine Propranolol Gabapentin Sleep medication Melatonin / sleep supplement

Which anxiety/sleep medications helped, caused sedation, caused dependence concerns, or affected functioning?

Overall Medication Effectiveness

Overall, how well is your current medication plan working? (0 = not working, 10 = working extremely well)

012345678910

What medication questions would you like addressed in therapy or with your prescriber?

Clinical Summary & Download

Current Medications Listed0

Previous Medications Listed0

Current Side Effects0

Overall Effectiveness--

AI-Style Clinical Summary

Generate Clinical Summary Copy Summary Print / Save as PDF Download Completed HTML Email Mark

Reminder: The email button opens your email app. You may still need to attach the saved PDF or downloaded HTML file manually.

This assessment supports therapy documentation and care coordination. It does not replace medical advice, medication management, diagnosis, or treatment by a licensed medical prescriber.

---

Please save and send to [email protected]

---