Page 22 - BARMC Guide 2017 MOBILE

My Next Appointment
Date ____________Time__________
Dr. Name ______________________
Specialty ______________________
Address _______________________
Dr. Ph. # _______________________
Reason for appointment _______________________________
Questions for my appointment
Check any of the boxes below and write notes to remember what to discuss with your doctor.
I have questions about:
r My medicines ______________________________ r My test results ______________________________ r My pain ______________________________ r Feeling stressed ______________________________ r Other questions or concerns ______________________________
______________________________
Notes
My Next Appointment
Date ____________Time__________
Dr. Name ______________________
Specialty ______________________
Address _______________________
Dr. Ph. # _______________________
Reason for appointment _______________________________
Questions for my appointment
Check any of the boxes below and write notes to remember what to discuss with your doctor.
I have questions about:
r My medicines ______________________________ r My test results ______________________________ r My pain ______________________________ r Feeling stressed ______________________________ r Other questions or concerns ______________________________
______________________________
My Next Appointment
Date ____________Time__________
Dr. Name ______________________
Specialty ______________________
Address _______________________
Dr. Ph. # _______________________
Reason for appointment _______________________________
Questions for my appointment
Check any of the boxes below and write notes to remember what to discuss with your doctor.
I have questions about:
r My medicines ______________________________ r My test results ______________________________ r My pain ______________________________ r Feeling stressed ______________________________ r Other questions or concerns ______________________________
______________________________
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NOTES APPOINTMENT KEEPER