Please complete this form prior to your next office visit to be reviewed before you arrive. This will optimize the time spent with you and better address the purpose for your visit. It can also be helpful to think through the details of your concern prior to discussing it with your practitioner. We look forward to seeing you soon!
Contact number where you can be reached for questions before your appt.
Chief Concern (ex. fatigue, lab results etc.)
History related to the problem (ex. Problem: Shortness of breath, Related History: Asthma since age 6.)
When did it start? How long has it been?
Where is the problem?
How long has this lasted? Happened previously?
Describe the problem (ex. Throbbing Pain, Shortness of breath when climbing stairs etc.)
What makes it worse?
What helps the problem?
How often? When does it happen? (ex. Occurs in the morning, 3 times in the last week.)
Rate the severity on a scale 1-10 (1 mild, 10 severe/worst). How bothersome is the problem?
Questions related to chief concern for your Nurse Practitioner, Tammy.
Other concerns you have that you would like to have addressed if there is time.
Areas / Topics you would like additional education or information on at some point in the future.
Health goals that you would like help achieving (may be unrelated to your next visit).
