UPCOMING APPOINTMENT WITH A NEW DOCTOR Why I am here: _ _____________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Important information you should know about my medical history: _ __________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Medications and allergies: _ __________________________________________________________________________ _____________________________________________________________________________________________________ Past surgeries and hospitalizations: __________________________________________________________________ _____________________________________________________________________________________________________ Other doctors I have seen: ___________________________________________________________________________ How I communicate best: ____________________________________________________________________________ Other things I want you to know about me:____________________________________________________________ _____________________________________________________________________________________________________ What should I know about you? ______________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Taking Charge of My Health Care
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