Patient Prep Card

Be Prepared

Fill in this card and bring it to your visit.

Today I want to talk about…

1. _____________________________________________________________________________

2. _____________________________________________________________________________

3. _____________________________________________________________________________

My questions are…

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

My health goals are…

_____________________________________________________________________________

_____________________________________________________________________________

Your next appointment is

Mon.   Tue.    Wed.    Thur.    Fri.    Sat.

Date: _______________________

at: _______________ AM[ ] PM[ ]

Page last reviewed November 2016
Page originally created November 2016
Internet Citation: Patient Prep Card. Content last reviewed November 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/prep-card.html