Appointment Brief
Blank — fill in by hand
This appointment
Patient name / date of birth
Date and time
Provider and location
Reason for the visit
What changed since the last visit
Current medications
| Medication | Dose | When taken |
|---|---|---|
Questions to ask
Write these down before you go — the three you most want answered, at the top.
1
2
3
4
What the doctor said
Next steps
| Follow-up, test, or referral | Who handles it | By when |
|---|---|---|