Main reason for today’s visit: _____________________________________________
Other concerns I would like to discuss if there is time: _______________________
Check all that apply:
o I have prescriptions that need to be refilled.
o I need a school or work excuse.
o I need a referral for my insurance company.
o I need the attached forms filled out.
o I would appreciate prayer today.
Patient’s name: __________________________________________________________
Date of birth: ___/___/___
Developed by Cornerstone Family Health, Williamsport, Pa. Copyright © 2003 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. “Focusing on Today’s Visit.” Redka JW. Family Practice Management. June 2003:59-60, www.aafp.org/fpm/ 20030600/59focu.html.
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