When you visit the physician's office there is a lot of information to share between you and your doctor in a short amount of time. It's easy to forget important questions or details that your doctor needs to know. This questionnaire is designed to help you get the most from your visit so you can feel your best.

Print out this form and take a few minutes to fill it out to take with you to the appointment.

Date of visit:


Reason for your visit:





When did the problem start?




Has the problem improved or worsened?
______ Improved
______ Worsened
______ About the same


What makes the problem worse?




How have you tried to treat your condition?





List any medicines you've taken for the problem.





Would you say you are a lot better, a little better, about the same, or worse than you were last visit?