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Date
Current Medication - if you know it, otherwise leave blank
Medication Type - if you know it, otherwise leave blank
No medication currently
Stimulant - like Concerta, Adderall, Vyvanse, Foquest, Dexedrine, Ritalin
Non-stimulant - like Strattera, Dayvigo
Anti-depressant - like Prozac, Effexor, Cipralex, Celexa, Wellbutrin
Mood Stabilizer - like Lamotrigine, Topamax
Atypical Anti-psychotic, like Abilify, Respirdone
Sedative - like Zopiclone
Opiates - Like Oxycodone, Suboxone, Methadone
Other
If 0 is the worst, and 10 is the best you can imagine, in the last week, How's your Mood?
Motivation?
Productivity?
Physical Energy?
Sleep?
Satisfaction with Life?
Social drive?
Self-esteem?
Piece of Mind?
Feeling Accepted?
Feeling Open (the opposite of guarded)?
Overall function, this week
Submit anonymously
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