Niti Logic Â· Free Worksheet

Provider Visit Preparation Worksheet

Complete before each appointment and bring it with you. Organized, specific information helps your provider spend visit time on your care.

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Provider Visits

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Visit Information

Patient Name

Date of Visit

Provider / Clinic

Specialty (if known)

Main Reason for Today's Visit â€” describe in one or two sentences

Top Concerns or Questions for This Visit

Question 1

Question 2

Question 3

Question 4

Symptom Details

When did symptoms begin?

Within last 24 hours

Within last week

Within last month

More than 1 month ago

Ongoing / chronic

Onset Pattern

Sudden

Gradual

Constant

Comes and goes

Worsening

If Pain â€” Character

Sharp

Burning

Dull ache

Pressure

Tingling

Pain Scale (0-10)

Location of Pain / Symptom

Current Medications

Medication	Dose	Frequency	Prescribing Provider	Side Effects?

Treatments Already Tried for This Problem

Medications

Physical therapy

Procedures / injections

Surgery

Home remedies

Lifestyle / diet changes

Chiropractic / alternative

Other

Results / Response to Prior Treatments

Tests or Imaging Already Done

Test / Imaging	When	Where / Facility	Results Available?

Provider Plan and Next Steps â€” Complete During or After Visit

Provider Notes / Instructions

Follow-up Timeframe

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