Patient Forms 


Get the most from your appointment with your provider by using these organizational tools. Jefferson Healthcare has created three organizational tools to help you keep track of the information you need to share with your provider.

1. Health History

Because a health history is so important for accurate and effective medical care, it is very helpful to you and your provider if you keep an ongoing journal to track every aspect of your health and medical care. This includes your general health, any major illnesses or diseases, hospitalizations, surgeries, therapies, and allergies.

Health History Form (PDF)

2. Symptom Log

A symptom log is used to track the specifics of your symptoms when you have a new illness. The more specific you can be, the better. The symptom log has a place for you to describe your chief complaint, a description of your symptoms, the severity of your symptoms (on a scale of 1 to 10), the approximate date your symptoms first presented, your observations about your symptoms, and other relevant details.

Symptom Log Form (PDF)

3. Medication Record

It is important for your provider to know all the medications you are currently taking. Among other reasons, this is important because
  • medications sometimes have negative side effects;
  • some medications negatively interact with others, and some block the action of others;
  • in certain cases, medications have a synergistic effect when combined, increasing the strength of one or both; and
  • some foods interfere with the action or absorption of certain medications.
Medication Record Form (PDF)

All of these tools are available from your clinic receptionist, or you may download them here.