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Patient Name:
*Reasons for Visit* Patient Questions
Date of Last Appointment With This Doctor: Date of Phone Call:
*Follow-up Items*Actions Taken by PatientDoctor's Recommendations
Notes
ResultsLabs/Tests/Date
*Visits with Other Clinicians*
Home Readings
Blood Pressure
Blood Sugar
Descriptions of VisitsClinicians/Date
Date of Visit: / /
Clinic MRN:
Nurse/MA Name:
Ongoing/Chronic ProblemsInformation Available?Attention
*Lab/Test Results*Information Available?
Information Available?Attention
Information Available?Attention
Attention
Information Available?Attention
Patient Age:
Role of Person Spoken to :
Patient Overview Document (POD)
PATIENT OVERVIEW PROCESS Clinic Name
Dr. Name
Health MaintenanceProcedure Results
Health Overview Changes/ProblemsDiet
Exercise
Sleeping Habits
Mood/Stressors
Pain
Alcohol Use
Tobacco Use
Living Arrangements
Falls
Notes
Date
*Medication Changes/Problems*
Changes/Problems/Concerns:
Refill? Name:
Dosage/Frequency:
Changes/Problems/Concerns:
Refill? Name:
Dosage/Frequency:
Changes/Problems/Concerns:
Refill? Name:
Dosage/Frequency:
Information Available?Attention
Information Available?Attention
Information Available?Attention
Eye Exam
Lipid Panel
Colonoscopy
Mammogram
Bone Density
Vaccinations
Changes/Problems/Concerns:
Name:
Dosage/Frequency:
Refill?