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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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