Skjema

Spørreskjema for bivirkninger av sentralstimulerende medikasjon

Sist oppdatert:

23. juli 2019

Barnets navn: __________________________________________________________ Født: ________________

Dato for utfyllingen: ______________________

Navnet på den som fyller ut skjemaet: __________________________________________________________

Hvilket medikament: ____________________________________________________________________________

Hvilken dose bruker barnet: ____________________________________________________________________

Besvar alle spørsmål. Dersom barnet har bivirkning, angi alvorlighetsgrad ved å skåre fra 1 til 9. Alvorlighetsgrad 9 betyr at bivirkningen er svært alvorlig eller forekommer svært hyppig.

Annonse

Sett kryss for ja/nei. Hvis ja - sett et kryss for et tall på skalaen fra 1-9.

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Annet, vennligst angi hva

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Etter original fra Barkley