Doctor'S Appointment Reminder Sheet Template (Page 2 of 2) in pdf

Doctor'S Appointment Reminder Sheet Template Page 2

CURRENT MEDICATIONS

Maintain an up-to-date list of all the medications, including over-the-counter products,

vitamins and herbal remedies. Be sure to: Keep a written list of the name, dose and

reasons for taking the medication. Update the list to include new prescriptions or

allergies. Review the list with the doctor at each office visit and keep it handy – in your

purse or wallet.

Dosage

How often

Reason for Medication

Medication

ALLERGIES: MEDICATION/OTHER (e.g. food, latex)

Allergic to

Allergic Reaction

HEALTH HISTORY

Illnesses and chronic conditions_______________________________________

________________________________________________________________

Accidents/Surgeries/Hospitalizations

________________________________________ Date: _____/_____/_______

________________________________________ Date _____/_____/________

Family History:____________________________________________________

________________________________________________________________

Have you signed or asked your doctor about an Advanced Directive? Yes No

Have you signed a Health Care Proxy? Yes No

Name of Health Care Agent _________________________ Tel #____________

Doctor'S Appointment Reminder Sheet Template Page 2