Medication Side-Effect Checklist

Since starting your memory medication, have you noticed any of the following? Please tick everything that applies.

There are no right or wrong answers — this helps us to check if the medication is suiting you.

1. Patient & medication details

Which medication do you take?
Have you noticed any possible side effects since starting?

Symptom checklist

Stomach and bowel
Sleep
Nervous system
Heart and circulation
Movement and balance
Muscles and other physical
Urinary
Mood or behaviour
Skin and allergic reactions

Impact and tolerability

Have these side effects affected your daily life?
Are you still taking your medication?
Overall, how well are you tolerating the medication?

Together We Can Do More

Spire Claremont Hospital

0114 263 0330

Circle Thornbury Hospital

0114 266 1133