University of FloridaSolutions for Your Life

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Publication #FCS2236

Doctor Appointment Checklist1

Carolyn Wilken2

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

Table 1. 

Prescription

Medication

Dosage

Frequency

Over-the-Counter Drugs

Dosage

Frequency

Supplements

and Vitamins

Dosage

Frequency

Notes:

Footnotes

1.

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.

2.

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-Chancy, Interim Dean.