Microsoft word - medise.doc

Psychiatric University Hospital Zurich, P.O. Box 68, CH-8029 Zurich, Switzerland Psychiatric University Hospital Zurich, Division of Clinical Psychiatry
MEDICATION AND SIDE EFFECTS
RATING DAY
CARD NUMBER
[ _ _ : _ _ : _ _ ]
DATE (dd.mm.yy)
[ _ _ : _ _ : _ _ ]
INTERVIEWER
HOSPITAL
PATIENT ID (the hospital’s internal PID)
[ _ _ _ _ _ _ _ _ _ _ _ _ ] 61-72
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland Please indicate medications by drug names (exact specification) and doses. The three-
digit medication codes (cf. page 4) can be filled in at a later time point by the study
administrator.
0 Card number
[ _ _ ] 13-14
1 1st Medication
[_____________________________________________] [ _ _ _ ] 15-17
[ _ _ _ _._ ] 18-22
2 2nd Medication
[_____________________________________________] [ _ _ _ ] 23-25
[ _ _ _ _._ ] 26-30
3 3rd Medication
[_____________________________________________] [ _ _ _ ] 31-33
[ _ _ _ _._ ] 34-38
4 4th Medication
[_____________________________________________] [ _ _ _ ] 39-41
[ _ _ _ _._ ] 42-46
5 5th Medication
[_____________________________________________] [ _ _ _ ] 47-49
[ _ _ _ _._ ] 50-54
6 6th Medication
[_____________________________________________] [ _ _ _ ] 55-57
[ _ _ _ _._ ] 58-62
7 Weight and Blood Pressure (to be measured at each rating day)
[ _ _ _._ ] 63-66
Blood pressure (systolic/diastolic)
[ _ _ _ ] 67-69
[ _ _ _ ] 70-72
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland Side effects
(0= none, 1= questionable, 2= light, 3= mild, 4= severe, 5= very severe) 0. Card number
[ _ _ ] 13-14
Disturbances
6. Other Autonomic Disturbances
2. Appetite
Disturbances
7. General
Disturbances
3. Sexuality
4. Gastrointestinal
Disturbances
8. Neurological
Disorders
5. Cardiac-respiratory
Disturbances
Laterality (0=no, 1=yes)
Convulsions (0=no, 1=yes)
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland 001 Abilify 5 10 15 30 mg 043 Fluanxol 0.5 1 5 mg 085 Ritalin SR 20 mg 002 Akineton 2 mg 044 Fluanxol Decanoas 20 100 mg/ml 086 Ritalin LA 20 30 40 mg 003 Akineton ret 4 mg 045 Fluctine 20 mg 087 Rivotril Tbl 0.5 2 mg 004 Akineton Ampullen 1 mg/ml 046 Fluctine 20 mg 088 Rivotril Lös 0.1 mg/ml 005 Anafranil 25 mg 047 Gutron 2.5 mg 089 Rohypnol 1 mg 006 Anafranil SR 75 mg 048 Halcion 0.25 mg 090 Saroten retard 25 50 mg 007 Aphenylbarbit 100 mg 049 Haldol 1 10 mg 091 Semap 20 mg 008 Atarax 25 mg 050 Haldol Decanoas 50 100 mg/ml 092 Serdolect 4 12 16 mg 009 Aurorix 150 mg 051 Hova 200/46 mg 093 Seresta 15 50 mg 010 Becozym forte 052 Imovane 7.5 mg 094 Seropram 20 mg 011 Beloc Zok 50 mg 053 Inderal 10 40 mg 095 Seropram Tropfen 40 mg/ml 012 Benerva 100 300 mg 054 Insidon 50 mg 096 Seroquel 25 100 200 300 mg 013 Benocten 50 mg 055 Jarsin 300 mg 097 Sinquan 50 mg 014 Buspar 10 mg 056 Jatrosum N 10 mg 098 Solatran 15 30 45 mg 015 Campral 300 mg 057 Keppra 500 mg 099 Solian 100 200 400 mg 016 Chloraldurat rot 250 mg 058 Lamictal 25 50 100 mg 100 Sulfarlem S 25 25 mg 017 Cipralex 10 mg 059 Leponex 25 100 mg 101 Subutex 0.4 2 8 mg 018 Clopixol 2 10 25 mg 060 Lexotanil 1.5 3 mg 102 Surmontil 25 100 mg 019 Clopixol Tropfen 20 mg/ml 061 Lithiofor 660 mg 103 Tegretol CR 200 400 mg 020 Clopixol Decanoas 20 mg/ml 062 Ludiomil 25 75 mg 104 Temesta 1 2.5 mg 021 Concerta retard 36 54 mg 063 Lyrica 25 .300 mg 105 Temesta expidet 1 2.5 mg 022 Concor 10 mg 064 Magnesiocard 10 mmol 106 Tenormin 50 100 mg 023 Dafalgan 500 mg 065 Mefenacid 250 500 mg 107 Timonil retard 300 mg 024 Dalmadorm 15 30 mg 066 Methadon streuli 5 mg 108 Tofranil 10 25 mg 025 Dapotum 5 mg 067 Mysoline 250 mg 109 Tolvon 30 60 mg 026 Dapotum D 25 100 mg/ml 068 Modasomil 100 mg 110 Topamax 15 50 100 mg 027 Deanxit 0.5/10 mg 069 Neurontin 400 mg 111 Torecan 6.5 mg 028 Demetrin 10 20 mg 070 Nexium 20 mg 112 Tranxilium 5 10 20 50 mg 029 Depakine chrono 300 500 mg 071 Nortrilen 25 mg 113 Trilafon 4 8 mg 030 Depakine Lösung 300 mg/ml 072 Noveril TR 240 mg 114 Trileptal 300 mg 031 Deroxat 20 mg 073 Nozinan 25 100 mg 115 Tript-OH 100 mg 032 Dipiperon 40 mg 074 Orfiril long 300 500 1000 mg 116 Trittico 50 100 mg 033 Distraneurin 192 mg 075 Priadel 400 mg 117 Truxal 15 50 mg 034 Dogmatil 200 mg 076 Prazine 25 50 mg 118 Urbanyl 10 mg 035 Dormicum 7.5 15 mg 077 Psychopax 12.5 mg/ml 119 Valium 2 5 10 mg 036 Edronax 4 mg 078 Quilonorm 536 mg 120 Valverde Schlaf 250/60 mg 037 Efexor 37.5 75 mg 079 Quilonorm retard 450 mg 121 Xanax 0.25 0.5 1 mg 038 Efexor ER 75 150 mg 080 Remeron 30 45 mg 122 Xanax retard 0.5 1 mg 039 Eltroxin 0.1 0.05 mg 081 Risperdal 0.5 1 2 3 4 mg 123 Zoloft 50 mg 040 Entumine 40 mg 082 Risperdal Lösung 1 mg/ml 124 Zolpidem Winthrop 10 mg 041 Eunerpan 5 mg/ml 083 Risperdal Consta 25 37.5 mg 125 Zyprexa 1.5 5 10 15 mg 042 Floxyfral 100 mg 084 Ritalin Tbl 10 mg 126 Zyprexa Velotabs 5 10 15 20 mg

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