Questionnaire about potential side effects of lithium treatment
| When did you start this treatment? (to be filled in only if the subject has received lithium treatment for at least 6 months) __________________________________ |
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| Since you began this treatment, have you experienced any of the following: |
| Gastrointestinal symptoms? |
| If yes, please specify: nausea, vomiting, diarrhea? ___________________________ |
| Impairment in psychic functioning? |
| If yes, please specify: sleepiness, lethargy? ________________________________ |
| Neurologic symptoms? |
| If yes, please specify: tremor, dizziness? __________________________________ |
| Muscular symptoms, such as muscle weakness? _________________________________ |
| Weight gain? |
| If yes, please specify: Weight before treatment: ____________ |
| Current weight: _____________ |
| Did you receive any other medication during this period? |
| If yes, which? ______________________________________________________ |
| Thyroid problems? |
| If yes, please specify: |
| Goiter alone? Date and circumstances of diagnosis: _________________________ _________________________________________ |
| Hypothyroidism? With associated goiter? Date and circumstances of diagnosis: __________________________________ |
| Has this hypothyroidism required hormonal substitution treatment? ___________ |
| If yes, since when? ________________________ |
| Hyperthyroidism? __________________________________ |
| Abnormal blood test results? If yes, please specify _______________________________ |
| An increase in fluid intake and the need to urinate during the day? ___________________ |
| If yes, how many liters of fluid do you drink each day? _______________________ |
| Do you need to get up during the night to drink or urinate? __________________ |
| Dermatologic effects? |
| If yes, please specify: acne, psoriasis: _____________________________________ |
| Do these dermatologic effects require treatment? ___________________________ |
| Sexual problems? __________________________________________________________ |
| Last serum lithium concentration measured on: __________________________________ |