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Simple tool to help doctors to help their patients make the most of their visit to the clinic

Posted Nov 18 2008 12:14am

Today’s Visit

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, 20030600/59focu.html.

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