Medication & Physical Health Form

Medication & Physical Health History

Please complete this form before your assessment. It helps Dr Musa Sami’s clinical team understand your medication history and relevant physical health background.

Patient details

Please confirm the details below.

Patient ID

Full name

Email address

Phone number

Current medication

Please tell us about any medication you are currently taking.

Are you currently taking any medication?

Current medication details

Past medication

Please tell us about any psychiatric or ADHD medication you have taken before.

Have you taken psychiatric or ADHD medication in the past?

Past medication details

Allergies and side effects

Please tell us about medication allergies or serious side effects.

Do you have any medication allergies?

Have you had serious side effects from any medication?

Allergy details

Side effect details

General physical health

Please tell us about any relevant physical health conditions.

Do you have any ongoing physical health conditions?

Physical health condition details

Thyroid problems

Kidney or liver disease

Glaucoma

Raynaud’s disease

Heart and circulation

Please answer these safety-related questions.

History of heart disease

Blood pressure problems

Palpitations

Chest pain

Dizziness

Fainting or unexplained falls

Heart / circulation details

Measurements

If known, please provide your recent measurements.

Height

Weight

Blood pressure reading

Pulse / heart rate

Supplements and over-the-counter medication

Do you take any supplements, vitamins, or over-the-counter medication?

Supplement / over-the-counter medication details

Additional notes

Anything else you would like Dr Musa to know?

I confirm that the information I have provided is accurate to the best of my knowledge.