Sample Doctor Visit Notes
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DATE OF VISIT: ________________________
DOCTORS’ NAME: ______________________ PHONE #: __________________ FAX #: _____________________
BLOOD PRESSURE: _____________________ WEIGHT: _________lbs. TEMP: __________
REASON FOR VISIT: __________________________________________________________________________________________
SYMPTOMS: _________________________________________________________________________________________________
_________________________________________________________________________________________________
START DATE OF SYMPTOMS/FREQUENCY: _________________________________________________________________________________________________
_________________________________________________________________________________________________
CURRENT MEDICATIONS: (Dosage & Frequency) Including OVER THE COUNTER DRUGS, HERBS, VITAMINS.
1. _________________________ 2. _________________________ 3. __________________________
4. _________________________ 5. _________________________ 6. __________________________
7. _________________________ 8. _________________________ 9. __________________________
10. _________________________ 11. _________________________ 12. __________________________
13. _________________________ 14. _________________________ 15. __________________________
16. _________________________ 17. _________________________ 18. __________________________
ALLERGIES: _________________________________________________________________________________________________
_________________________________________________________________________________________________
DIAGNOSIS / OPINION: _____________________________________________________________________________
DOCTOR RECOMMENDATIONS: _____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
TREATMENT PERFORMED ON DAY OF VISIT: __________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INJECTIONS: ____________________________ TESTS: __________________________________________________
ADDITIONAL MEDICAL SERVICES:
LAB WORK: ___________________________
X-RAYS: ___________________________
CT SCAN: ___________________________
MRI: ___________________________
OTHER: ___________________________
NEW MEDICATIONS PRESCRIBED: ______________________________________________ DOSE: ____________
_______________________________________________ DOSE: ____________
NEW MEDICATIONS SIDE EFFECTS: _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
REFERRALS TO SPECIALISTS: ___________________________ PHONE: __________________
______________________________________________________________________________
DATE TO CALL FOR TEST RESULTS: ____________________________
DATE OF FOLLOW-UP APPT. _________________
ADDITIONAL NOTES: _______________________________________________________________________________________________
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