Doctor Questionairre
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HARMED Hearts
Doctor Informed Consent Worksheet — Venlafaxine (Effexor®)
Patient name:
Date:
Doctor name:
Clinic/Contact:
Part 1 — Basics (doctor completes)
- Diagnosis/indication:
- FDA-approved for this condition? ☐ Yes ☐ No (off-label)
- Starting dose + titration schedule:
Part 2 — FDA Black Box Warning (suicidality)
- I explained the FDA suicidality warning (higher risk up to age 24; risk when starting/changing doses). Doctor initials:
- I advised family/loved ones on red flags to monitor and when to seek help. Doctor initials:
Part 3 — Half-Life & Withdrawal
- I explained venlafaxine’s short half-life (≈5 h IR, ≈11 h XR) and that missed/late doses can trigger rapid withdrawal. Doctor initials:
- We discussed a slow, individualized taper; abrupt stopping is unsafe. Doctor initials:
Part 4 — Receptor Occupancy (pharmacology)
- At common doses (≈75–150 mg), serotonin transporter occupancy is typically ~80–90%. Doctor initials:
- We discussed how high occupancy may relate to emotional blunting and withdrawal severity. Doctor initials:
Part 5 — Side Effects discussed
- Emotional blunting / reduced empathy. Doctor initials:
- Sexual dysfunction (desire, arousal, orgasm). Doctor initials:
- Blood pressure increases / monitoring plan. Doctor initials:
- Sleep disturbance, sweating, headaches, dizziness. Doctor initials:
- Weight change (gain or loss). Doctor initials:
- Serious risks: serotonin syndrome, heart rhythm changes, seizures. Doctor initials:
Part 6 — Pregnancy & Postpartum
- Risks in pregnancy (neonatal adaptation, preterm/low birth weight) discussed. Doctor initials:
- Breastfeeding: milk transfer & possible infant withdrawal discussed. Doctor initials:
- Potential impact on maternal bonding/emotional responsiveness discussed. Doctor initials:
Part 7 — Monitoring & Follow-Up
- First follow-up scheduled within weeks.
- Contact if symptoms worsen/adverse effects:
- Safety plan (how family responds to red flags) reviewed. Doctor initials:
Patient signature:
Date:
Clinician signature:
Date:
