Medication Trials Checklist

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Client/Patient Name: __________________________________________________ Date _________________________

Prescription Name Helped No

Help Not

Tolerated Reason Stopped Taking 5-HTP Abilify Maintena Abilify Aristada (Airpiprazole Lauroxil) Adderall, Adderall XR Alprazolam (Xanax) Amitriptyline (Elavil) Amoxapine Antabuse Aripiprazole (Abilify) Asenapine (Saphris) Atenolol (Tenormin) Buprenorphine (Suboxone, Subutex) Bupropion (Wellbutrin) Busipirone (Buspar) Campral Carbamazepine (Tegretol) Chlordiazepoxide Chlorpromazine (Thorazine) Citalopram (Celexa) Clomipramine (Anafranil) Clonazepam (Klonopin) Clonidine (Catapress) Clorazepate (Tranxene) Clozapine (Clozaril) Desipramine (Norpramin) Desvenlafaxine (Pristiq) Diazepam (Valium) Diphenhydramine (Benadryl) Doxepin (Silenor) Doxepin (Sinequan) Droperidol Duloxetine (Cymbalta) Escitalopram (Lexapro) Estazolam Eszopiclone (Lunesta) Fetzima (Levomilnacipram) Fluoxetine (Prozac) Fluphenazine (Prolixin) Flurazepam Fluvoxamine (Luvox) Folate Gabapentin (Neurontin) Guanfacine (Tenex) Haldol Decanoate Haldolperidol (Haldol) Hydroxyzine (Vistaril) Iloperidone (Fanapt)

Medication Trials Checklist

Page 2 of 3  

Client/Patient Name: _________________________

Prescription Name Helped No

Help Not

Tolerated Reason Stopped Taking Imipramine (Tofranil) Invega Sustenna Invega Trinza (Palperidone) Isocarboxazid (Marplan) Kava Kava Lamotrigine (Lamictal) Licorice Root Lithium Lorazepam (Ativan) Loxapine (Loxitane) Lurasidone (Latuda) Ma Juang Maprotiline Maprotiline (Ludiomil) Melatonin Methadone Methylphenidate, Ritalin, Concerta Milnacipran (Savella) Mirtazapine (Remeron) Molindone (Moban) Naloxone (Narcan) Naltrexone (Revia, Vivitrol) Nortriptyline (Pamelor) Nuplazid (Pimavanserin) Nuvigil Olanzapine (Zyprexa) Oxazepam Oxcarbazapine (Trileptal) Palperidone (Invega) Paroxetine (Paxil) Perphenazine (Trilafon) Phenelzine (Nardil) Pimozide (Orap) Pregabalin (Lyrica) Propranolol (Inderal) Protiptyline (Vivactil) Quazepam (Doral) Quetiapine (Seroquel) Ramelteon (Rozerem) Rexulti (Brexpiprazole) Risperdal Consta Risperidone (Risperdal) Selegiline (Emsam) Serentil (Mesoridazone) Sertraline (Zoloft) Serzone (Nefazodone) St. Johns Wart

 

Medication Trials Checklist

Page 3 of 3  

 Client/Patient Name: _________________________ 

 

Prescription Name Helped No

Help Not

Tolerated Reason Stopped Taking Straterra Temazepam (Restoril) Thioridazine (Mellaril) Thiothixene (Navane) Thyroid Medication Tiagabine (Gabitril) Tiapride Topiramte (Topamax) Tranylcypromine (Parnate) Trazodone (Desyrel, Oleptro) Triazolam (Halcion) Trifluoperzaine (Stelazine) Trimipramine (Surmontil) Valerian Root Valproic Acid (Depakote) Venalfaxine (Effexor) Viibryd (Vilazodone) Vitamin B12 Vitamin D Vraylar (Cariprazine) Vortioxetine (formerly known as Brintellix; Now called Trintellix)

Vyvanse Zaleplon (Sonata) Ziprasidone (Geodon) Zolpidem (Ambien) Zonisamide (Zonegran) Zyprexa (Relpreevv)

Client/Patient Name: _________________________________________________________________ Date: _________________ Printed Name: _____________________________________________________________________________________________ Signed: ___________________________________________________________________________________________________ Relationship to Client/Patient: ________________________________________________________________________________