Journal of Medical Appointments

Patient Name: __________________________________________________________________________

Date: ____________________

Medical Professional & Type: _____________________________________________________________

Location: _______________________________________________________________________________

Reason for visit: _________________________________________________________________________

Symptoms: _____________________________________________________________________________

Questions: _____________________________________________________________________________

 _______________________________________________________________________________________

Diagnosis: ______________________________________________________________________________

  
Recommendations: ______________________________________________________________________

_______________________________________________________________________________________ 

Prescribed Medications: __________________________________________________________________

_______________________________________________________________________________________

Tests and Immunizations: ________________________________________________________________

_______________________________________________________________________________________

Reason for & dates of tests: ________________________________________________________________

_______________________________________________________________________________________

Test results & dates: _____________________________________________________________________

_______________________________________________________________________________________

Referrals & follow-up appointments: ________________________________________________________

_______________________________________________________________________________________

Blood pressure: __________________     Height: _________________         Weight: _________________