What problems would you like to discuss at today's visit?
Do you need any refills on your medications today? If so, please list them below. Please let us know if you need a 1 month supply, or if you want a 3 month supply of your medicines.
Please check-off any problems you have had in the past MONTH that you would like to discuss further (please feel free to write in more detail next to the problem or at the bottom of the page):
|Significant weight LOSS|
|Significant weight GAIN|
|Restless - always need to be doing something|
|Thinking about hurting yourself or others|
|Can't get motivated to do anything|
|No enjoyment in your life|