Pre-Visit “Ask the Doctor” Checklist

On the go but need to keep track of your questions to ask your doctor today? Fill out this form and send a copy of it to your email account to save and refer back to for your appointment. Save them within your email account to refer back to as well! (Your email will not be retained or used for any other purposes, this is a tool made specifically for you as our patient!)

Questions To Ask The Doctor:

Check the boxes below to remember the following questions to ask the Doctor:

If the Doctor wants you to take new medicine, ask:
If the Doctor wants you to take a test, ask:
At the end of your Doctor's visit, ask:
Email Address to send your "Ask-the-Doctor" Checklist:(Required)
This field is for validation purposes and should be left unchanged.

Print a paper copy of the “Ask the Doctor” checklist, fill it out and bring it with you before seeing your doctor at your next appointment! Click below to get started.


(English Worksheet)
(Spanish Worksheet)