Name:__________________________
Main reason for today’s visit:
__________________________________________________________________________________
__________________________________________________________________________________
Do you have any changes to your address or insurance information?
Yes (list here)_____________________________________
No
Check all that apply:
I have the following prescriptions that need to be refilled:___________________________________________
I need a school or work excuse
I need a referral to:_______________________________________
Have you had any lab work, x-rays, or other tests done recently?
Yes, If so where & when? ___________________________________
No
Have you been seen by a specialist recently, or started on any new medications, or had
any changes in medications?
Yes (explain)_____________________________________________
No
Any changes to your family’s health (blood relatives?)
Yes (explain)_____________________________________________
No
Which pharmacy do you use? __________________________________
Is today’s visit work related?
Yes No
Other concerns I would like to discuss if there is time:
Please note that due to time constraints we may need to address these issues at a
future appointment.___________________________________