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?|