Personal Health Assessment Page 2

List any over-the-counter medications you take regularly or on occasion:

List any herbs or supplements you’ve been taking since your last visit:

List any difficulties you’ve had taking your medications as prescribed:

Is there anything else you’d like to include?

Your doctor is here to help you with any questions, comments, or concerns you may have about your health. Is there

anything you can think of that may help during your next office visit?

Great!

If you’ve taken the time to fill out this health assessment, you’ll have helpful information to share with your

doctor during your next visit. Remember: the more prepared you are, the more meaningful the discussion with your

doctor will be.

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Parent category: Medical