Next Visit Information
When you and your health care team such as your doctors, nurse, and pharmacist are working together,
your health can only improve. Plan your next visit. Know what your goals are, or at least the questions
that you want answered.
Basic Information
Todays date (yyyy-mm-dd) : _____________ Birthday (yyyy-mm-dd): _______________
E-mail address: _____________________
First name: _________________________ Last name: _____________________________________
Address: _____________________________________________________________
City: ______________ Postal Code: _______________
Telephone # home: ___________________ Work _____________ Best time to call: ____________
Medications
Always bring a list of all your medications including doses to every physician visit. Complete the list
below: Medication Dosage Reason for taking
______________ _________ __________________________ ______________ _________
__________________________ ______________ _________ __________________________
______________ _________ __________________________ ______________ _________
__________________________ ______________ _________ __________________________
______________ _________ __________________________ ______________ _________
__________________________ ______________ _________ __________________________
______________ _________ __________________________
How often do you forget to take your medication? ___ Never ___rarely ___ sometimes _____ frequently
If you are having any side effects or you are not taking your pills properly do not adjust them on your
own but discuss them with your physician or pharmacist: Allergies or Side Effects:
_________________________________________________
Questions
Medical issues are becoming more and more complex. Most physician visits are brief. While not all
issues may be addressed, having a list and setting priorities are important steps. Primary or main
question: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other questions that I would like addressed:
________________________________________________________________________
_________________________________________________________________
________________________________________________________________________
Current Medical issues and Medical History
(Please check all that apply):
__ loss of appetite __ failing vision __ nausea/vomiting
__ difficulty swallowing __ diabetes type 1 __ diabetes type 2
__ leg pain when walking __ dizzy/fainting spells __ stroke
__ heartburn __ thyroid disease __ bronchitis/chronic cough
__ seizures __ asthma/wheezing __ shortness of breath
__ gallbladder trouble __ headaches __ cancer
__chest pain with activity __worsening chest pain __ muscle soreness/weakness
__ jaundice/hepatitis __arthritis/rheumatism __ palpitations
__ blood transfusions __ diarrhea/constipation __ back pain
__ bloody or tarry stools __ blood in urine __ peptic ulcer
__ AIDS/HIV __ sexual concerns
__ swollen ankles __ osteoporosis __ gout
__ sleep apnea __ sleep difficulty
__ anemia/bruise easily __ weight loss/gain
__ depression/anxiety __ suicidal
Female patients please complete Menstrual flow: __ regular __ irregular__ __ flushing/menopausal
symptoms Date of last period _______
Key Measurements
The best way to treat a disease is to prevent it from happening.
Blood Pressure ________ / _________
What is your cholesterol? _______ Minutes of activity per week: ______________
What is your blood sugar (A1C)? __________ Are you watching your diet: _______________
Weight: ________ lbs or _______ kg
Are you a smoker? ______ Cigarettes per day: _____Quit date (yyyy-mm-dd): _______
Are there stresses in your life or are you depressed: ______
Do not take your health for granted. Prepare for your next physician visit. Keep a copy for your records
and leave one for your physicians chart. Do not be afraid to say to your doctor that you do not
understand certain points of your health.
Emergencies
Call 911 for true emergencies or use a hospitals Emergency Room (ER) service for emergencies like
chest pain coming from your heart unrelieved by 3 sprays of Nitro taken 5 mins apart that lasts greater
than 15 mins.