At each visit, your doctor will likely ask about your concerns. It’s a good idea to think about what you’d like to talk about before the actual visit. This form can help you organize your thoughts. Make a copy of the blank form so you will always have a clean copy to use. Then, after you make an appointment, take a minute to write down the name of the doctor and the appointment details (for example, the date, time, and address). Use the form to make a list (in order, from most important to least important) of the concerns you want to discuss.
Doctor:
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Appt. Date:
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Time:
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Address:
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Phone:
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Appointment Details (#1 Most Important to Least Important)
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1.
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2.
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3.
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4.
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5.
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6.
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7.
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8.
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Notes:
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