# New-doctor health summary

Prepared for: [clinician or practice]

Appointment date: [YYYY-MM-DD]

Summary last verified: [YYYY-MM-DD]

This is a patient-prepared orientation page, not a complete medical record. Verify important details against the listed sources and the receiving office's intake process.

## Evidence key

- **Verified:** checked against a report, medication container, pharmacy record, portal entry, or clinician note
- **Patient-reported:** my observation or recollection
- **Uncertain:** useful detail whose date, dose, wording, or source is not confirmed
- **Missing:** a record or detail I still need to obtain

## Visit goal

[One sentence explaining why I am establishing care or attending this visit now.]

## Top three priorities

1. [Highest-priority concern or decision]
2. [Second priority]
3. [Third priority]

## Current observations

- Concern: [what I notice]
- Evidence state: [patient-reported / verified / uncertain]
- Started: [date, approximate date, or uncertain]
- Pattern or change: [frequency, better/worse/changing, or unknown]
- Functional impact: [sleep, work, mobility, eating, exercise, caregiving, or daily tasks]
- Prior evaluation or source: [record title, date, source ID, or none]
- Question: [what I want reviewed]

## Medicines, supplements, and allergies

Medication list current as of: [YYYY-MM-DD]

For each prescription, over-the-counter medicine, vitamin, herb, or supplement:

- Name: [exact label]
- Strength or dose: [value or not sure]
- How and when taken: [instructions or not sure]
- Stated purpose: [if known]
- Prescriber, pharmacy, or source: [name or source ID]
- Start, stop, or change date: [date or not sure]
- Evidence state: [verified / patient-reported / uncertain]

Allergies and reactions:

- Item: [medicine, substance, or other item]
- Reaction: [exact documented or remembered reaction; do not guess]
- Evidence state and source: [verified / patient-reported / uncertain plus source]

## Selected history and five-event timeline

Include only history that helps orient this visit. For each item:

1. [Date] - [event or documented condition] - [evidence state] - [source]
2. [Date] - [event] - [evidence state] - [source]
3. [Date] - [event] - [evidence state] - [source]
4. [Date] - [event] - [evidence state] - [source]
5. [Date] - [event] - [evidence state] - [source]

## Care team and pharmacy

- Primary or prior clinician: [name, organization, relevant contact]
- Specialist: [name, organization, relevant contact]
- Pharmacy: [name, location, relevant contact]
- Trusted support person and role: [optional]

## Selected records attached

- [Record title] - [date] - [organization] - [why included] - [filename or source ID]

## Missing or uncertain records

- [What is missing or uncertain] - [approximate date or organization] - [request status] - [why it may matter]

## Ranked questions

1. [Most important question]
2. [Second question]
3. [Third question]

## Communication and access needs

- Preferred language or interpreter request: [if applicable]
- Hearing, vision, mobility, cognitive, sensory, or other accommodation: [if applicable]
- Preferred name and pronouns: [optional]
- Companion role and any private-visit request: [optional]

Do not delay urgent care while completing this template. Contact a qualified clinician or emergency service when symptoms or results may be urgent.