Medication consent

Patient Name: __________________________________ DOB___________________ Medication Consent
1. Elevated Blood Sugar, Diabetes Mellitus and Stroke: I have been informed by the undersigned that elevated blood sugars, in some cases extreme, and associated with coma or death have been reported in patients treated with atypical antipsychotics including but not limited to: CLOZARIL, RISPERDAL, ZYPREXA, SEROQUEL, GEODON, INVEGA and ABILIFY. The relationship between atypical antipsychotic use and elevated blood sugar is not completely understood because of other factors such as the higher incidence of diabetes in the general population and other factors. However, studies suggest an increased risk of elevated blood sugar and cholesterol related adverse events in patients treated with atypical antipsychotics. These changes may occur with or without weight gain. Any patient treated with atypical antipsychotics should be monitored for symptoms of elevated blood sugar including increased thirst, increased urination, increased eating and weakness. Patients who develop symptoms of elevated blood sugar during treatment with atypical antipsychotics should have a test for elevated blood sugar and cholesterol. In addition RISPERDAL, ZYPREXA and ABILIFY have been found to have an elevated risk of stroke in clinical trials in elderly patients with dementia. 2. I have been informed by the undersigned that all antipsychotic medication that I take (including those listed in #1 above as well as haloperidol (HALDOL) and fluphenazine (PROLIXIN) may result in a condition called Tardive Dyskinesia (TD). The symptoms of TD, which is potentially irreversible, have been explained to me. 3. If applicable (female of child bearing age): I have been informed by the undersigned that any and all medication I take may have a negative effect on an unborn child (fetus) if I am pregnant. If I am not pregnant now, I agree to discuss my medication(s) with my doctor before attempting to get pregnant. If I do become pregnant while taking medicine I agree to immediately contact my doctor. 4. I have been informed by the undersigned that benzodiazepines, for example, lorazepam (ATIVAN), alprazolam (XANAX), and clonazepam (KLONOPIN) are addicting, and may cause dizziness, impaired memory, impaired coordination and reaction time, and should not be combined with alcohol. I understand that I should not stop taking these medications abruptly because of the risk of possible seizures and/or other adverse effects. 5. I have been informed by the undersigned that the Food and Drug Administration (FDA) has issued a warning that antidepressants might worsen depression and/or increase the risk of suicide. Patients and their families should be alert for the emergence of agitation, irritability, anxiety, panic attacks, insomnia, hostility, impulsivity, severe restlessness, worsening depression, suicidal thoughts, or elevated mood, especially soon after treatment has been started, the dose of the medication has been increased or decreased, or when the medication is discontinued. 6. I have been informed by the undersigned that one or more of the medications I have been prescribed are “off label.” This means that the medication is prescribed for uses not approved by the Food and Drug Administration (FDA). Only atomoxetine (STRATTERA) for ADHD, fluoxetine (PROZAC) for depression and obsessive compulsive disorder (OCD), sertraline (ZOLOFT) for OCD and clomipramine (ANAFRANIL) for OCD have FDA approval for use in children. 7. Amphetamines have a high potential for abuse. Administration of amphetamines for prolonged periods of time may lead to drug dependence. Particular attention should be paid to the possibility of subjects obtaining amphetamines for non- therapeutic use or distribution to others and the drugs should be prescribed or dispensed sparingly. Misuse of amphetamine may cause sudden death and serious cardiovascular adverse event s. 8. Sedative-hypnotic drug products have risks which include severe allergic reactions and complex sleep-related behaviors, which may include sleep-driving. Sleep driving is defined as driving while not fully awake after ingestion of a sedative- hypnotic product, with no memory of the event. 9. I have been informed by the undersigned that one or more of the medications prescribed to me may adversely affect my ability to drive a motor vehicle or operate machinery, and I take full responsibility for this liability. 10. Potential risks and benefits of taking this or these medications, as well as alternative treatment, have been discussed with me and I accept these risks. I have been given a copy of this form to take home with me. I have been given the opportunity to ask questions, have received answers and therefore I understand the preceding statements.



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