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ASK Self-Help Group Medication Record
Remember, to be successful, keep it honest, focusedand most of all, simple.

HELP YOUR MEDICATION(S) WORK FOR YOU

Keep a daily log on the medication you are taking.

Today's date:____________________________

Name of your medication(s). Generic or regular brand:__________________________

Number of milligrams:____________________________________

Your daily dosage:____________________________________

·How are you feeling as a result of the medication at any given timeduring the day:____________________________________________________
Side effects:___________________________________________
How is your mood in the evenings:_______________________________
What are your sleeping patterens:___________________________________
What skills do you want to improve: _____________________________
What improvements are you seeing :________________________

   
 
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