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):

Excessive fatigue
Significant weight LOSS
Significant weight GAIN
Trouble sleeping
Feeling nervous/anxious
Excessively irritable
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