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
Sores on your feet
Blurred vision
Shortness of breath
Chest pain
Swelling in your feet/ankles
Hypoglycemic (low blood sugar) episodes
Trouble feeling things in your feet