Personal Health Assessment Page 4

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

Ibuprofen and 24-hour sinus relief.

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

Ginseng, echinacea, flaxseed, and calcium.

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

Sometimes I forget to take my medications on time.

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?

Are there any support groups you’ d recommend?

It’ s getting harder and harder to cook dinner.

My kids are worrying about me.

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