Doctor Appointment Checklist1
Name: ____________________________________________________ Date: ________________
What is the primary reason for this appointment? ____________________________________________________________________________________________________________________________________________________________________________________
Is this a new problem or symptom?
____________________________________________________________________________________________________________________________________________________________________________________
Describe the symptoms or problems you are having? ____________________________________________________________________________________________________________________________________________________________________________________
When are the symptoms most noticeable? ____________________________________________________________________________________________________________________________________________________________________________________
What have you tried that has not helped relieve symptoms? ____________________________________________________________________________________________________________________________________________________________________________________
This is affecting my daily life in these ways. ____________________________________________________________________________________________________________________________________________________________________________________
Tables
Prescription Medication |
Dosage |
Frequency |
Over-the-Counter Drugs |
Dosage |
Frequency |
Supplements and Vitamins |
Dosage |
Frequency |
|
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Notes: |
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Footnotes
This document is FCS2236, one of a series of the Department of Family, Youth and Community Sciences, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Publication date: June, 2005. Reviewed: September 2008 by Tina Lam, MD, and Mary Harrison, professor, Department of Family, Youth, and Community Sciences, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Please visit the EDIS Web site at http://edis.ifas.ufl.edu.
Carolyn Wilken, PhD, associate professor, of the Department of Family, Youth and Community Sciences, Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, 32611.
The Institute of Food and Agricultural Sciences (IFAS) is an Equal
Opportunity Institution authorized to provide research, educational
information and other services only to individuals and institutions
that function with non-discrimination with respect to race, creed,
color, religion, age, disability, sex, sexual orientation, marital
status, national origin, political opinions or affiliations.
For more information on obtaining other extension publications,
contact your county Cooperative Extension service.
U.S. Department of Agriculture, Cooperative Extension Service,
University of Florida, IFAS, Florida A. & M. University Cooperative
Extension Program, and Boards of County Commissioners Cooperating. Millie Ferrer, Interim Dean.
