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patient form: take notes during your visit

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Take Notes During Your Visit Here is a list of things you might want to write down during your doctor’s visit: 1) My doctor said I have (new diagnosis, disease, or condition) 2) My doctor wants me to start/change the following medications: Medication Name: Dose: When/How Often: 3) My doctor wants me to stop (list medicine, smoking, foods, alcohol, etc.) 4) My doctor wants me to start (exercise, special diet, treatment, therapy, etc.) 5) My doctor wants me to see a specialist: Doctor Name: When: For: Contact Info: 6) My tests today showed: Test Name: Result: Doctor’s Recommendation 7) Additional notes (special instructions, etc.) 8) My doctor wants me to come back or call back on:

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Page 1: Patient Form: Take Notes During Your Visit

Take Notes During Your VisitHere is a list of things you might want to write down during your doctor’s visit:

1) My doctor said I have(new diagnosis, disease, or condition)

2) My doctor wants me to start/change the following medications:

Medication Name: Dose: When/How Often:

3) My doctor wants me to stop(list medicine, smoking, foods, alcohol, etc.)

4) My doctor wants me to start(exercise, special diet, treatment, therapy, etc.)

5) My doctor wants me to see a specialist:

Doctor Name: When: For:Contact Info:

6) My tests today showed:

Test Name: Result: Doctor’s Recommendation

7) Additional notes (special instructions, etc.)

8) My doctor wants me to come back or call back on:

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