Your Medical Visit
Date: ____________________ Dr. Name _______________________
Primary Reason For Visit:
Example: Review test results, medication refill, sickness etc.
Example: Sore throat, rash, pain etc. (try to note the date it began)
Example: I fell in poison ivy, I have had a fever for 3 days, etc.
If time permits other concerns or questions you may have:
Example: Tests, medication required or follow up appointments.