| Medication | Dosage | Dates Prescribed | Expected Result |
1. _______________________________________________________
Is the medication working? Are you feeling better, and able to do more? Yes _______ No _______
Comments: ________________________________________________
2. _______________________________________________________
Is the medication working? Are you feeling better, and able to do more? Yes _______ No _______
Comments: ________________________________________________
3. _______________________________________________________
Is the medication working? Are you feeling better, and able to do more? Yes _______ No _______
Comments: ________________________________________________
4. _______________________________________________________
Is the medication working? Are you feeling better, and able to do more? Yes _______ No _______
Comments: ________________________________________________
5. _______________________________________________________
Is the medication working? Are you feeling better, and able to do more? Yes _______ No _______
Comments: ________________________________________________
Created by Compassionate Choices/ Modified by Consoling Grace.