DoctorPatient YesNo Risk factors (check all that apply): Missed doseFear about taperingPast failureDistinction (relapse vs withdrawal)Slow metaboliserHigh doseStart issuesPrevious switchOther Duration of use: <1 year1-2 years2-5 years5-10 years>10 years Current usage: [repeater usage] [/repeater] Other oral medication: [repeater other_meds] [/repeater] Tablets are desired form of administration Patient consents to information transfer with local pharmacy Patient information: MF Doctor information: I confirm that all information is truthful. Request form for a free TAPERING RECOMMENDATION After completing this form, your request will be sent to Regenboog Apotheek. Who is filling in this form? DoctorPatient Patient Information Gender: MenFemale Tapering Details Is the patient currently free from symptoms? [radio* symptom_free use_label_element "Yes" "No"] 1a. Risk factors (check all that apply) Missed dose – withdrawal symptoms after missing 1 doseFear about taperingPast failure – previous attempts failedDistinction – need to distinguish relapse vs withdrawalSlow metaboliser – low dose = high plasma concentrationHigh dose – >100% DDD for >6 monthsStart – problems at start of treatmentPrevious switch – changed psychiatric medication beforeOther 1b. Duration of medicine use [radio* duration use_label_element "<1 year" "1–2 years" "2–5 years" "5–10 years" ">10 years"] 1c. Current usage of medicine 1d. Other oral medication 1e. Other information 1f. Desired form of administration Yes, tablets preferred 1g. Desired tapering period 1h. Consent to share with pharmacy Yes, I give permission 1i. Health insurance Prescribing Doctor Confirmation [acceptance* acceptance-1] I confirm that all requested information has been provided truthfully. [/acceptance]
