Sample Medication Worksheet

Name_______________________     Completed By____________________________

Date of Birth_________________       Age_______   Sex_______     Grade________

Date Form Completed__________

 Medication(s)                                              Dosages and Times Administered Per Day                   

 ____________________________    __________________________________________

 Mark any changes noticed in the following behaviors:

Main Effects on Behavior          Worse              No Difference             Improved         Improved

                                                                                                                           a little                 a lot

 Attention to task                       _____                    ______                  _______          ______

 Listening to lessons                  _____                    ______                  _______          ______

 Finishing assigned work          _____                    ______                  _______          ______

 Impulsivity                                _____                    ______                  _______          ______

 Calling out in class                   _____                    ______                  _______          ______

 Organizing work                       _____                    ______                   _______          ______

 Overactivity                              _____                    ______                  _______          ______

 Restless, fidgety                       _____                    ______                 _______          ______

 Talkative                                    _____                    ______                  _______         ______

 Aggressive                               _____                    ______                  _______          ______

 Peer Interaction                       _____                    ______                 _______          ______

 

Mark any side effects which you have noticed or which the child has mentioned.

 Side Effects                                          Comments

 _____ Appetite loss                 ________________________________________________

 _____ Insomnia                        ________________________________________________

 _____ Headaches                    ________________________________________________

 _____ Stomachaches               ________________________________________________

 _____ Seems tired                   ________________________________________________

 _____ Stares a lot                    ________________________________________________

 _____ Irritability                       ________________________________________________

 _____ Excessive crying            ________________________________________________

 _____ Motor/ vocal tic             ________________________________________________

 _____ Nervousness                  ________________________________________________

 _____ Sadness                         ________________________________________________

 _____ Withdrawn                    ________________________________________________

 

Source: the ADD Hyperactivity Handbook for School by Harvey C. Parker, Ph.D.