Medication history

RDCRN#: 5202
Medication History Form
Growth Hormone:
Is your child currently on growth hormone? O Yes O No If applicable, what type of growth hormone? If not currently, has your child ever been on growth hormone in the past? O Yes O No If applicable, how old was your child when he/she started growth hormone? ________ years If applicable, how old was your child when he/she stopped growth hormone? ________ years If growth hormone was stopped, why was it discontinued? (Indicate all that apply) □ Side effects (describe) __________________________________ □ Due to age/ had stopped growing □ Child’s decision □ Behavioral problems □ Insurance would not pay □ Research study completed □ Other (describe) _____________________ Sex Hormones:
Males Only:
Is your child currently on testosterone? O Yes O No If not on currently, has your child ever been on testosterone in the past? O Yes O No If applicable, how old was your child when he started testosterone? _________ years RDCRN#: 5202
Medication History Form
If applicable, how old was your child when he stopped testosterone? _________ years What type of administration of the testosterone? (check box) If testosterone was stopped, why was it discontinued? (Indicate all that apply) □ Other side effects (describe) _________________________________ □ Other (describe)____________________________________________ Females Only:
Is your child currently on estrogen? O Yes O No If not on currently, has your child ever been on estrogen in the past? O Yes O No If applicable, how old was your child when she started estrogen? __________ years If applicable, how old was your child when she stopped estrogen? _________ yea7rs □ Oral contraceptives (type): Dose___________ O Monophasic-Alesse RDCRN#: 5202
Medication History Form
□ Premarin/provera: Dose ______mg per day □ Premarin only: Dose ______mg per day □ Depo-provera: Dose _______ mg/ml □ Progesterone only: Dose______ mg □ Other (please list name and dose) __________________________ If estrogen was stopped, why was it discontinued? Other side effects (describe) _______________________________________ Other (describe) _________________________________________________ Psychotropic medications:
Is your child currently on or have they ever been on any of the following medications? (indicate all that apply – leave dose blank if you do not know) SSRI’s
Prozac(fluoxetine) O Yes O No Dose ___________ from _____ to _____ O Ongoing Zoloft (sertraline) O Yes O No Dose ___________ from _____ to _____ O Ongoing Paxil (paroxetine) O Yes O No Dose ___________ from _____ to _____ O Ongoing RDCRN#: 5202
Medication History Form
Other: please specify__________________ O Yes O No Dose ___________ from _____ to _____ O Ongoing Antidepressants
O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Other: please specify __________________ O Yes O No Dose ___________ from _____ to _____ O Ongoing Antiepileptics
O Yes O No Dose ___________ from _____ to _____ O Ongoing Tegretol (carbamazepine) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Stimulants
Provigil (modafanil) O Yes O No Dose ___________ from _____ to _____ O Ongoing Ritalin (methylphenidate) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Antipsychotics
Risperdal (risperidone) O Yes O No Dose ___________ from _____ to _____ O Ongoing Seroquel (quetiapine) O Yes O No Dose __________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Haldol (haloperidol) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing How would you rate the effectiveness of the psychotropic medication(s) your child is currently on?  not effective  somewhat effective  effective  very effective Do you have any comments on past psychotropic medications your child has been on? ________________________________________________________________________________________________________________________________________________________________ RDCRN#: 5202
Medication History Form
Is your child currently on or have they ever been on any of the following medications? (indicate all that apply – leave dose blank if you do not know) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Saliva stimulants (e.g.biotene) O Yes O No Dose ___________from _____ to _____ O Ongoing DDAVP (desmopressin) O Yes O No Dose ___________ from _____ to _____ O Ongoing Metformin (glucophage) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Dose ___________ from _____ to _____ O Ongoing Other diabetes medication O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________from _____ to ____ O Ongoing Other asthma medication O Yes O No Dose _________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Multivitamin O Yes O No Dose ___________ from _____ to _____ O Ongoing RDCRN#: 5202
Medication History Form
O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing

Source: http://www.mammag.uci.edu/kimonis/docs/03032008_937_5202_Medication_History_17-Dec-07.pdf