Health Medication Quiz

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Full Name *

Email Address *

Phone

Do you feel that your medication is effectively managing your symptoms (e.g., mood, anxiety, focus)? *

Not at all Occasionally Frequently Nearly every day

Have you experienced unwanted side effects (e.g., weight gain, sleep problems, numbness, fatigue)? *

Not at all Occasionally Frequently Nearly every day

Do you feel emotionally “numb” or disconnected while on your medication? *

Not at all Occasionally Frequently Nearly every day

Have you had trouble remembering to take your medication consistently? *

Not at all Occasionally Frequently Nearly every day

Have you noticed new or worsening symptoms since starting your medication? *

Not at all Occasionally Frequently Nearly every day

Do you feel your provider has not explained your medication or options clearly? *

Not at all Occasionally Frequently Nearly every day

Do you feel unsure whether you should stay on, stop, or change your medication? *

Not at all Occasionally Frequently Nearly every day

Have you had thoughts of stopping your medication without talking to your provider? *

Not at all Occasionally Frequently Nearly every day

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