Information Sheet for Clinic Visits
Your Name:
Date of Birth:
Today’s date:
Primary Care Provider (Automatically receives our clinic note unless you tell us otherwise)
Name:
Address:
Additional healthcare providers who should receive copies of the clinic note
Name:
Address:
Name:
Address:
Medications:
I take the following prescription medications
Medication
Size of pill,
tablet, dose
How many times a day
I take the following non-prescription (over the counter) medications
Medication
Size of pill,
How many times a day
tablet, dose
I take the following alternative or complementary medicine treatments
Treatment
Size of pill, tablet, dose
How many times a day,week,
month
I am allergic to the following medications:
Medication
Questions or concerns for this visit:
Nature of allergic reaction