Family Medication Prescription Request

You have requested us to send you a repeat prescription for your young person’s medication. Please fill in the following medication report, and tick the acknowledgment below.

Child's Name(Required)

Date of Birth(Required)

Please list the medication(s) that your young person is prescribed (please include the doses and the time they usually take them).

Please list the medication(s) that you require scripts for and the urgency (eg. Indicate if you only have a couple of tablets left).

Please list the conditions or problems that the medications are treating.

Please consider and rate the following categories (rate over the last 2 months):

Do you have any other comments on the benefits or the side effects of your child's medication treatment?

Are there any changes you would like to request regarding your young person’s medications?

If relevant, please indicate below the frequency of side effects from your medications since your last medical review. Please consult your GP for any urgent medical needs.

	Not at all	Sometimes	Often	All the time
Appetite reduction
Weight loss
Weight gain
Stomach aches
Nausea
Vomiting
Diarrhoea
Dryness (skin, nose, mouth)
Thirst
Sore throat
Sleep difficulties
Tics
Headache
Muscular tensions
Fatigue
Dizziness
Sweating
Agitation/excitability
Irritability
Mood instability
Over focus "zombie effect"
Sadness
Heart palpitations
Blood pressure changes (significantly lower or higher)
Frequent urination
Sexual dysfunction
Feeling worse or different when the medication wears off (rebound effect)

Acknowledgement

I acknowledge that I have provided the information above to the best of my knowledge and this information is what will be used to guide my child’s treatment.

I am aware that the prescription may have been made without a clinical appointment and review.

I am aware that a fee will be charged for the prescription service. I confirm financial consent for this payment.

I have a GP who I can see if there are urgent issues that arise that require urgent review.

Please confirm the email and/or mobile number to send an eScript to:

Guardian name(Required)

Mobile number(Required)

Email(Required)

Where To Find Us

Woodend (Head Office)

Sunbury (Melbourne)

Mildura

Bendigo

	Much worse	A little worse	No change	A little better	Much better
Symptom Control (eg. ADHD, Depression, Anxiety)
Side effects
Overall life function

Family Medication Prescription Request

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