Page 13 - MagSampleGuideRevised
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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 ______________________________
11
APPOINTMENT KEEPER NOTES
