Current Medication List Form
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1CURRENT MEDICATION LIST
Name:______________________________Birthdate:_______________
Todays date:__________________
DIFFICULTY
WHODAS - In the past 30 days, how much
did you have:
Standing for long periods,
None
Mild
Moderate
Severe
Extreme or
such as 30 minutes?
Cannot do
Taking care of your
None
Mild
Moderate
Severe
Extreme or
household responsibilities?
Cannot do
Learning a new task, for
None
Mild
Moderate
Severe
Extreme or
example, learning how to
Cannot do
get to a new place?
How much of a problem did
None
Mild
Moderate
Severe
Extreme or
you have joining in social
Cannot do
activities?
How much have you been
None
Mild
Moderate
Severe
Extreme or
emotionally affected by your
Cannot do
health problems?
Concentrating on doing
None
Mild
Moderate
Severe
Extreme or
something for ten minutes?
Cannot do
Walking a long distance,
None
Mild
Moderate
Severe
Extreme or
such as a mile?
Cannot do
Washing your whole body?
None
Mild
Moderate
Severe
Extreme or
Cannot do
Getting dressed?
None
Mild
Moderate
Severe
Extreme or
Cannot do
Dealing with people you do
None
Mild
Moderate
Severe
Extreme or
not know?
Cannot do
Maintaining a friendship?
None
Mild
Moderate
Severe
Extreme or
Cannot do
Your day-to-day work?
None
Mild
Moderate
Severe
Extreme or
Cannot do
Number of
Overall, in the past 30 days, how many days were these difficulties present?
days:________
In the past 30 days, how many days did you reduce your usual activities or work because of
Number of
any health condition?
days:________
In the past 30 days, for how many days were you totally unable to carry out your usual
Number of
activities or work because of any health condition?
days:________
List all meds you are taking
Name of Med:
Dose:
Times a day:
Time of day taken:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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| Current Medication List 2016
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