Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) Page 10
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15AG-095 (11-14) – Page 10
CLIENT’S NAME
DAARS ID NO.
E.
Medications/Treatments (Select the most appropriate answer.)
1.
Are you taking your medications as prescribed?
Yes (Skip question #2.)
No (Ask question #2.)
No medications needed.
2.
Are you able to buy the medications you need?
Yes
No (If no, select all the reasons below that apply.)
Income
Health insurance
Transportation
Not available in area
Other:
None.
List medications below (If none, select “None”):
Restore List
Prescribed Medications
Over-the-Counter (OTC) Medications
Total number of Prescription Medications:
None
Check if continuation sheet attached.
Total number of OTC Medications:
None
Information obtained from:
Drug allergies?
Yes (specify):
Medical records
Prescription bottles
No, no known allergies
Self-report
Other (specify):
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