Systematic Monitoring of Adverse events Related to Treatment

Systematic Monitoring of Adverse events Related to Treatment


Instructions:

We want to be sure that you are receiving the best treatment, and
would like to check whether you have any problems which may result
from taking your medications.

Please circle any of the following items that trouble you, so that your
doctor or nurse can discuss them with you.

Are you troubled by:


1. Difficulties in your movement such as shaking, stiffness or muscle aches?

2. Changes in your weight or appetite?

3. Problems with your sex life?

4. Changes in your periods or changes in your breasts?

5. Dizziness or light-headedness?

6. Tiredness or sleepiness?

7. Restlessness or feeling fidgety?

8. Constipation, diarrhoea, nausea, stomach problems or dry mouth?



9. Difficulty passing water or passing water very frequently?

10. Problems with your concentration or memory?

11. Feeling anxious or depressed?

12. Any other problems which you think may be related to your medication?

Please state   and consult your doctor for adverse events.