Csp informed consent meds

CRISIS STABILIZATION / RESIDENTIAL DETOXIFICATION PROGRAM
Informed Consent for Medication
Consumer: _____________________________ ___CSP ___ Detox ___ Dual Chart # _____________ While you are at the Crisis/Detox/Touchstone Dual Diagnosis Program for care and treatment one of the following classes of medications may be prescribed to you. The side effects and adverse reactions are listed below. Your signature gives Crisis Stabilization Unit physician/nurse practitioner permission to prescribe the medication as well as the nursing staff permission to administer the medication. * Some of the medications are monitored by required lab studies/ blood work. Neuroleptics:
Abilify, Clozaril*, Compazine, Geodon, Haldol, Loxitane, Mellaril, Navane, Prolixin/Permitil, Risperdal, Risperdal Consta, Seroquel, Sparine, Thorazine, Trilafon, Zyprexa, Zydis. (Circle Prescribed Medication) Side effects include: Sedation, muscle spasms, dry mouth, constipation, blurred vision, rapid heart beat, Parkinson symptoms: tremor, muscle stiffness, shuffling walk, drooling, dizziness, low blood pressure, pacing or weight gain. Date: __________ Consumer Signature: _______________________________ _________________________________ M.D./N.P Antidepressant:
Asendin, Elavil, Celexa, Cymbalta, Desyrel, Effexor, Lexapro, Luvox, Norpramin, Paxil, Pamelor, Prozac, Remeron, Sinequan, Tofranil, Vivactil Zoloft, Wellbutrin. (Circle Prescribed Medication) Side effects include: Sedation, dry mouth, constipation, blurred vision, rapid heart beat, drop in blood pressure, increase blood pressure, weight gain, weight loss, nausea/ GI upset, restlessness, tremor, headache, fatigue, insomnia or dizziness. Date: __________ Consumer Signature: _______________________________ __________________________________ M.D./N.P Antimania:
Depakene*, Depakote*, Lamictal*, Lithium*, Tegretol*, Topamax*. (Circle Prescribed Medication) Side effects include: Increased thirst, nausea, fine hand tremor, dizziness, weight gain, increased urination, stomach cramps, sleepiness, loose stools, dry mouth, muscle weakness, restlessness, headache and serious rashes. Date: __________ Consumer Signature: _______________________________ __________________________________ M.D./N.P Antianxiety:
Atarax, Ativan, Buspar, Equanil, Centrax, Librium, Paxipam, Valium, Vistaril, Tranxene, Xanax (Circle Prescribed Medication) Side effects include: Potentially addictive, sedation, fatigue, confusion, or blurred vision. Benefits: Date: __________ Consumer Signature: _______________________________ __________________________________ M.D./N.P Anticholinergic:
Artane, Benedryl, Cogentin. (Circle Prescribed Medication) Side effects include: Dry mouth, constipation, blurred vision, and nausea. Benefits: Date: __________ Consumer Signature: _______________________________ __________________________________ M.D./N.P Anticonvulsant:
Dilantin, Tegretol, Klonopin, Dapakene, Neurontin, and Phenobarbital (Circle Prescribed Medication) Side effects include: Drowsiness, nausea, vomiting, blurred vision, headache, sleeplessness, or sore gums. Benefits: Date: __________ Consumer Signature: _______________________________ __________________________________ M.D./N.P CSP 14 Revised 10/09/07

Source: http://www.albanycsb.org/P&P/Attachments/CSP_14_Informed_Consent_for_Medication.pdf