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Dr. Grimshaw the office your visit & Newsletters Health Risk |
Internal and Geriatric Medicine
Recognized Provider "With Distinction" by the
American Diabetes Association/National Committee
for Quality Assurance 2/99-2/02
Clinical Associate Professor of Medicine,
New York Medical College
The reason for your visit to Dr. Grimshaw
When you visit the physician's office there is a lot of information to share between you and your doctor in a short amount of time. It's easy to forget important questions or details that your doctor needs to know. This questionnaire is designed to help you get the most from your visit so you can feel your best.
Take a few minutes to fill out this form, print it, and take it with you to
the physician's office.
Tip: There are
only 5 lines available per question, so summarize information as much as
possible. If you type more than 5 lines it won't show on the
printout.
IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page after entering the data so you don't lose your information.
| Date of visit: |
Reason for your visit:
When did the problem start?
| Has the problem improved or worsened? |
What makes the problem worse?
How have you tried to treat your condition?
List any medicines you've taken for the problem.
IMPORTANT TIP: The information you
entered is not saved to protect your privacy. Please print this page now so you
don't lose your information.