Appointment Agenda Form

This is a prototype form for use with your PCP visit, as described in Self Advocacy for Diagnosis.  With the help of your feedback and suggestions, an actual form that you can print out will be created.  Make supplemental documents as for Medication List, Current symptoms and Health Issues and Past Medical History when indicated.

November 2, 2018

Name: _____________________         Medical ID______________     Provider name  __________________
 

DOB:  __________                                                                                        Visit date  __________
 

 

Main reason for visit: 

 

Other main concerns today: (3 maximum)

 Medical history since last visit:   (If first visit with provider, list recent changes)

 

New symptoms:

​Changes in medications and treatments:

Illnesses, Hospitalizations, ER, Urgent care:

Specialty visits:

 

Xrays, Procedures, Labs:

 

Sample Form

Name: _____________________         Medical ID______________     Provider name  __________________
 

DOB:  __________                                                                                        Visit date  __________
 

 

Main reason for visit: Increased fatigue and difficulty concentrating at work.  This has been getting worse for many months. Started about a year ago.

 

Other main concerns today:

  1. Legs jerky/ buzzy at night off and on. Hard to sleep!

  2. Feet burning and tingling—for several years, getting worse

  3. Severe headaches for many months

Medical history since last visit:   (If first visit with provider, list recent changes)

 

New symptoms:

  1. Hair loss- noticed at last haircut

  2. Chest pain after dinner (off and on x 2 mo)

  3. Pain and bloating in my gut ( x 6 mo)

​​​Changes in medications and treatments:

Started acupuncture 2 months ago.Relaxing, but no overall improvement

Illnesses, Hospitalizations, ER, Urgent care:

​Urgent Care:Treated for sinus infection Sept. 2018

Specialty visits:

None recent. Have endocrine consult next month for bone density

 

Xrays, Procedures, Labs:

Dexa scan shows osteoporosis (Aug. 2018)