|Glasgow Antipsychotic Side-Effect Scale (GASS)
| Gender: <.Patient_Gender.>
| 21. Women only: I have noticed a change in my periods
| <*Answer_8840*>
| Level of distress: <*Answer_8841*>
|
| Weight Gain
| 22. Men and women: I have been gaining weight
| <*Answer_8842*>
| Level of distress: <*Answer_8843*>
|
|Information contained in this note is based on a self-report assessment
|
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| GASS Total Score = <-Total->
|
| Scores indicate the following side effect severity:
| 0-21 absent/mild side effects
| 22-42 moderate side effects
| 43-63 severe side effects
|
|
|
|Questions and Answers:
|
| Please list current medication and total daily doses below:
| <*Answer_8799*>
|
| Sedation and CNS Side Effects
| 1. I felt sleepy during the day
| <*Answer_8800*>
| Level of distress: <*Answer_8801*>
| 2. I felt drugged or like a zombie
| Date Given: <.Date_Given.>
| <*Answer_8802*>
| Level of distress: <*Answer_8803*>
|
| Cardiovascular Side Effects
| 3. I felt dizzy when I stood up and/or have fainted
| <*Answer_8804*>
| Level of distress: <*Answer_8805*>
| 4. I have felt my heart beating irregularly or unusually fast
| <*Answer_8806*>
| Level of distress: <*Answer_8807*>
| Clinician: <.Staff_Ordered_By.>
|
| Extra Pyramidal Side Effects
| 5. My muscles have been tense or jerky
| <*Answer_8808*>
| Level of distress: <*Answer_8809*>
| 6. My hands or arms have been shaky
| <*Answer_8810*>
| Level of distress: <*Answer_8811*>
| 7. My legs have felt restless and/or I couldn't sit still
| <*Answer_8812*>
| Location: <.Location.>
| Level of distress: <*Answer_8813*>
| 8. I have been drooling
| <*Answer_8814*>
| Level of distress: <*Answer_8815*>
| 9. My movements or walking have been slower than usual
| <*Answer_8816*>
| Level of distress: <*Answer_8817*>
| 10. I have had uncontrollable movements of my face or body
| <*Answer_8818*>
| Level of distress: <*Answer_8819*>
|
|
| Anticholinergic Side Effects
| 11. My vision has been blurry
| <*Answer_8820*>
| Level of distress: <*Answer_8821*>
| 12. My mouth has been dry
| <*Answer_8822*>
| Level of distress: <*Answer_8823*>
| 13. I have had difficulty passing urine
| <*Answer_8824*>
| Veteran: <.Patient_Name_Last_First.>
| Level of distress: <*Answer_8825*>
|
| Gastro-intestinal Side Effects
| 14. I have felt like I am going to be sick or have vomited
| <*Answer_8826*>
| Level of distress: <*Answer_8827*>
|
| Genitourinary Side Effects
| 15. I have wet the bed
| <*Answer_8828*>
| SSN: <.Patient_SSN.>
| Level of distress: <*Answer_8829*>
|
| Screening Question for Diabetes Mellitus
| 16. I have been very thirsty and/or passing urine frequently
| <*Answer_8830*>
| Level of distress: <*Answer_8831*>
|
| Prolactinaemic Side Effects
| 17. The areas around my nipples have been sore and swollen
| <*Answer_8832*>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| Level of distress: <*Answer_8833*>
| 18. I have noticed fluid coming from my nipples
| <*Answer_8834*>
| Level of distress: <*Answer_8835*>
| 19. I have had problems enjoying sex
| <*Answer_8836*>
| Level of distress: <*Answer_8837*>
| 20. Men only: I have had problems getting an erection
| <*Answer_8838*>
| Level of distress: <*Answer_8839*>
|
