Priority Pediatrics PC

Side Effect Patient Check List

Please register on my Updox Portal BEFORE starting this questionnaire, if you have not already previously registered, so that your work can be saved and completed in more than one seating if needed. Once you are registered on the Portal, you will be able to retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form information and need to start over. When completed, click SEND and the form will come securely to me. Thank you. Dr. T

Patient Name * Person Completing Check List * Date of Form Completion *

Have you experienced and of the following side effects or problems in the past week?

Headache * Stomachache * Change of appetite--explain below * Explain/Comment Trouble Sleeping * Irritability in the late morning, late afternoon, or evening-explain below * Explain/Comment Socially withdrawn-decreased interaction with others-explain below * Explain/Comment Extreme sadness or unusual crying or tears * Feeling dull, tired, suppressed, listless behavior * Tremors, feeling shaky * Having repetitive movements, tics, jerking, twitching, eye blinking- explain below * Explain/Comment Picking at skin, nail biting, lip or cheek chewing-explain below * Explain/Comment Sees or hears things that are not there__that others don't see or hear * Are there any comments or further explanations you wish to add?

Thank you for taking the time to answer these important questions for Dr. T.