Viv's tips: Form to use when you visit a new doctor

Here is a form I created that might help some people. Print it and fill it out prior to going to visit a new doctor.


DATE:_________________

PCP____________________Referred by___________________

Describe your problem and symptoms:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Personal Medical History


___diabetes _________average diabetic reading _______Heart trouble
___asthma _________ Hay Fever ________Shortness of breath
___Bi-Polar _________ Anxiety ________ Trouble Sleeping
___Wear eyeglasses _______High Blood Pressure _______Broken bones


Family Medical History

___diabetes ______Heart trouble _______asthma_____Hay Fever
_____Shortness of breath ______High Blood Pressure


Current Medications

Please list all medications you are currently taking along with the dosage and time:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Is there anything else I should be aware of as your new Physician?
_________________________________________________________
_________________________________________________________
_________________________________________________________

What other Physician's are you under the care of?
_________________________________________________________
_________________________________________________________
_________________________________________________________


I hope and pray this form helps someone today.

FibroViv