The table below may help you and your doctor decide if you are sensitive to medications and potentially a candidate for customized strengths of medications.
Are you sensitive to any prescription or nonprescription drugs? If so, please list and describe.
How are you affected by alcohol? Check one and describe:
Easily Moderately Not Affected
Do some drugs make you tired or sleepy? If so, please list and describe:
Cold or allergy remedies or antihistamines (such as Benadryl, Claritin, Contac, Tavist):
Tranquilizers or anticonvulsants (such as Ativan, Valium, Xanax):
Others, such as motion-sickness remedies or antinausea agents:
Do some drugs give you energy or cause anxiety or insomnia? If so, please list and describe:
Coffee, tea, chocolate, other caffeine- like substances:
Appetite suppressants (prescription or nonprescription):
Cold or allergy remedies or decongestants (such as Sudafed):
Others:
Have you ever had a reaction to epinephrine (adrenaline chloride, often injected by dentists along with pain-numbing medication)?
Typical reactions include palpitations, sweating, anxiety and headaches.
Yes No
Have you had any side effects from any other prescription or nonprescription drugs
(such as impaired memory or coordination, blurred vision, headaches, indigestion, diarrhea, constipation, dizziness, palpitations,
rashes, swelling, ringing in the ears, other reactions)?
If so, please list the drugs and describe side effects:
Overall, how would you describe yourself with regard to medications?
Very sensitive
Not particularly sensitive
Very tolerant; usually require high doses
This may help you and your doctor decide if you are sensitive to medications and potentially a candidate for customized strengths of medications.
If you wish to print a blank template, click here to view the page in PDF format...
*Adapted from: Cohen, J.S. "Ways to Minimize Adverse Drug Reactions: Individualized Doses and Common Sense Are Key." Postgraduate Medicine, Sept. 1999;106:163-72.
311 Sherbourne St, Toronto, On M5A 3Y1 1-416-960-7768 OCP Accreditation number 17533, owner is Central Medical Pharmacy Inc. Designated manager is Veronique Koo, B Sc Phm. Pharmacists are available for counselling during operating hours.
The information provided on our site is for general information purposes only and is not intended to qualify, supplement or replace that of your medical professional. Your doctor or healthcare giver should undertake diagnosing and treating your medical condition.
