Patient Questionnaire - Reason for visit

Please fill in the following information to help your doctor fully understand the nature of your problem. This questionnaire is designed to save time and help you get the best treatment so you can feel your best.

Please fill out this form and take a printed copy to your physician's office.

 

Date: (05/18/01)
Reason for your visit:
When did the problem start?
Has the problem improved or worsened?
What makes the problem better or worse?
Have you treated or been treated previously for this condition?
Y
N
If yes, what was the treatment and by whom?
Are you taking any medications for the problem?
Y
N
If yes, which ones?