Ceg progress note sheet ceg

“Medical Wellness & Life Balance” Client Name: _____________________________________________ Date: ____________ I am on the following medication: Birth Control_______________ Is there a Chance you are pregnant? _____ If on CARBATROL, TRILEPTAL, or DEPAKOTE and female, what birth control method do you use?_________________________________________________________________________________________________ Take HERBAL REMEDIES? Specify, ________________________________________________________________________ Vitamins? _______________________________________________________ ALLERGY SHOTS? ______________________ Do you have Mitral Valve Prolapse?_____________ LIST YOUR ALLERGIES: ___________________________________________________________ CURRENT MEDICATION you are taking (include meds you were taking on your last session here). List each medication and daily dosage.
1. _______________________________! ________! 2. _______________________________ !__________ 3. _______________________________! ________! 4. _______________________________! __________ 5. _______________________________! ________! 6. _______________________________! __________ New Medication since your last session. Please include over the counter medication: 1. _______________________________! __________! 2. _______________________________! __________ 3. _______________________________! __________4. _______________________________! Other doctors, psychologists, coaches, or ministers you have seen since your last session: ______________________________________________________________________________________________________________ ***Positive Changes in Your Life Since Last Session: ____________________________________________________ ______________________________________________________________________________________________________________ ***Challenges In Your Life Since Last Session: _________________________________________________________ ______________________________________________________________________________________________________________ ***Things I would like to discuss and or evaluate with the doctor, nurse, coach, or minister today: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Return Date: _________________ Coach(es): _________________________________________ Date: _________________

Source: http://coreempowermentgroup.md/Forms_files/CEG-Progress%20Note%20Sheet_2.pdf