Medication Side-Effect Checklist

This form is for your appointment with Dr Jha. It is not checked out of hours, so please don’t use it for anything urgent: call 999 in an emergency, or NHS 111 or your GP for other urgent problems.

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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

Full name *

Date of birth *

Which medication do you take? *

• Donepezil tablet
• Rivastigmine tablet
• Rivastigmine Patch
• Memantine tablet

Approximate date medication started *

Have you noticed any possible side effects since starting? *

• Yes
• No

Symptom checklist

Stomach and bowel

• Nausea (feeling sick)
• Vomiting
• Diarrhoea
• Constipation
• Indigestion or stomach discomfort
• Reduced appetite
• Weight loss
• Black, tarry stools or blood in vomit ← red flag

Sleep

• Difficulty sleeping (insomnia)
• Vivid dreams or nightmares
• Increased daytime sleepiness

Nervous system

• Dizziness or light-headedness
• Headache
• Increased confusion
• Hallucinations (seeing or hearing things that are not there)

Heart and circulation

• Slow pulse or heartbeat
• Palpitations (awareness of heartbeat)
• Fainting, collapse or blackouts ← consolidated syncope item

Movement and balance

• Increased unsteadiness
• Falls since starting the medication

Full how tell

Muscles and other physical

• Muscle or leg cramps
• Excessive saliva or drooling
• Excessive sweating

Urinary

• Passing urine more frequently
• Urgency or difficulty controlling urine

Mood or behaviour

• Increased anxiety
• Increased agitation
• Increased irritability

Skin and allergic reactions

• Rash
• Itching
• Swelling of the lips, face or tongue ← red flag (angioedema)
• Redness, itching or rash if Rivastigmine patch is applied

Any other symptom?

Impact and tolerability

Have these side effects affected your daily life? *

• Not at all
• A little
• Moderately
• Quite a lot
• Severely

Are you still taking your medication? *

• Yes, every day
• Most days
• Occasionally missed doses
• I have stopped taking it

If you have stopped, please tell us why

Overall, how well are you tolerating the medication? *

• Very well
• Quite well
• Acceptably
• Poorly
• Very poorly

Submit

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