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?