things i don`t want to forget

NAME:
DATE:
PROVIDER:
THINGS I WANT TO REMEMBER
What are the most important things I would like
to talk about at my visit today?
(provider: check if discussed)
1. ____________________________________
____________________________________
____________________________________

2. ____________________________________
____________________________________
____________________________________

3. _____________________________________
_____________________________________
_____________________________________

Anything else:
_____________________________________
_____________________________________
_____________________________________
Examples:
-Symptoms
-Lab results
-Referrals
-Medications
-Side effects
-Concerns
-Forms
-Diet
-Excercise
For MA: Patient needs help to fill out?  No  Yes ------>Time spent for form_____mins.
NAME:
DATE:
PROVIDER:
COSAS QUE QUIERO RECORDARME
¿Cuáles son las cosas más Importantes que quiero
hablar en mi visita de hoy?
(provider: check if discussed)
1. ____________________________________
____________________________________
____________________________________

2. ____________________________________
____________________________________
____________________________________

3. _____________________________________
_____________________________________
_____________________________________

¿Algo más?
_____________________________________
_____________________________________
_____________________________________
Ejemplos:
-Síntomas
-Resultados de laboratorio
-Medicinas
-Necesidades Familiares
-Efectos Segundarios
- Referencias
-Dieta
-Ejercicio
For MA: Pt. needs help to fill out?  No  Yes ------->Time spent for form_____mins.