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CLINICIAN SUPPORT MATERIALS

Followup Session Template

Medication Management Support for Alcohol Dependence

   
 
Vital signs (if taken):BP: ____ / ____
P: _____ Weight: _____  
Laboratory data (if available):  GGT: ______ AST: _____ ALT: _____ Other: ___________
General progress and patient concerns since the last visit: _________________________________________________
_______________________________________________________________________________________________
Observations of patient cognition: ___________________Mood: __________________________________
     Physical signs: _______________________________Other: __________________________________
Drinking status
  • How long since the last drink? ______ days/weeks/months
  • In the past 30 days (or since the last visit if less than 30 days):
    - how many drinking days (any alcohol): ______ days in the past ______ days
    - how many heavy drinking days (5+ drinks/day for men, 4+ drinks/day for women):
         ______ days in the past _______ days
    Other: ____________________________________________________________
Alcohol pharmacotherapy
  • Medications prescribed:
    _______________________________________________________________
  • In the past 30 days (or since the last visit if less than 30 days), how many days has the patient taken medication? _____ days in the past ______ days
  • Side effects:
    ________________________________________________________________
  • Patient’s perception of the medication’s effectiveness:
    _______________________________________________________________
Other treatment received
Since your last visit, have you:
Yes No 
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
   ________________________________________
____________________________________________
____________________________________________

Counseling provided (check the dialogue used)

Is the patient drinking?
step 1 No or Yes
No
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Yes
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Is the patient adherent
to medications?

step 2 no yes

Is the patient adherent
to medications?

step 2 no yes
No
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Yes
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No
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Yes
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Other recommendations (e.g., side effects management, new adherence plan): ___________________________

___________________________________________________________________________________________
Followup:  Continue the current treatment plan
Change the treatment plan as follows:
 _________________________________________________________________________
(for nurses): Refer to physician for medical evaluation
Next appointment date: _________________________________________________

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