223 (223)    MH REPORT (601.93)

|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*>