HealthCare Provider Appointment Name: ________

HealthCare Provider Appointment Date: ________

Do I have transportation to Appointment?  Yes/No

If no; how will I get to appointment?  _________

Will someone be going with me to the Appointment?  Yes/No

If yes; who: ________

I plan to take the following items to my appointment with my HealthCare Provider

  • Pain Diary
  • Medication List
  • Completed "Preparing for a Visit with my HealthCare Provider Tool"
  • Other

I want to remember to ask my HealthCare Provider the following questions: 

  1. ________
  2. ________

I want to remember to share the following information with my HealthCare Provider:

  1. My major concern(s):
  2. Major Changes happening in my life (i.e. divorce, death of a loved one, etc.):
  3. Other Information:

Date/Time of next appointment:

PDF iconPreparing for a Visit with my HealthCare Provider Tool - PDF Version