Reason for Visit

Patient Visit Questionnaire: Reason for Visit

When you visit your Health Coach's office there is a lot of information to share between you and your doctor and it's easy to forget important questions or details that your doctor needs to know. This questionnaire is designed to help you get the most from your visit so you can feel your best. Take a few minutes to fill out this form, print it, and take it with you to the physician's office. Tip: summarize information as much as possible. What you type past the borders in the boxes will not show on the printout. To protect your privacy, the information you enter will not be saved.

Your name:

Date of visit:

Reason for your visit: (i.e., Chief Problem / Complaints)--do not type past the borders or your entry will not print out.

When did the problem start? When did you last feel well? In what setting did this problem develop? How has this affected you?

Has the problem improved, persisted, or worsened?

Describe your problem / symptom(s) in terms of

Location of symptoms (e.g., head, chest, abdomen, pelvis, limbs, etc.)
    Do symptoms radiate (move) to other areas? Specify.

Quality: (e.g., sharp pain, dull ache, vague sensation, etc.)

Quantity or severity
Timing
    onset (e.g., abrupt, gradual):
    duration: seconds minutes hours days
    frequency: x / day x / week x / month)
Setting: (e.g., with meals, at work, with walking, etc.)
What makes the problem worse?
What relieves the problem?
Any associated manifestations?

Has this problem been investigated by any other licensed medical physician?
Yes No Who ? When?
Were any medical tests performed on you regarding this problem? Yes No
If so what? (e.g., blood tests, EKG's, X-Rays, scans, MRI's, biopsies, etc.)

What were their results?

Please bring a copy of these results to your visit, or better still the actual films if possible.

Have you tried to treat your condition by any other means? (e.g., Chiropractor, Naturopath, Osteopath, Herbalist, Acupuncture, Massage, etc.) If so, whom did you visit? When? What were you told? What was advised? ?

List any medication you've taken for the condition. Please include any and all over-the-counter remedies (e.g., creams, syrups, vitamins, herbs, powders, teas, tonics, etc.)