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.





Do you have any of the followign problems:

Sore throat   If so, for how long and how severe?
Cough   If so, for how long and how severe?
Sinus/nose drainage   If so, for how long? What color is the drainage?
Body aches   If so, for how long?
Fever   If so, how high was the fever?
Nausea or vomiting  
Diarrhea   If so, how many times per day?
Headache   If so, how severe is your headache (1 to 10)?
Ear pain   If so, which ear?