Ask the patient to complete the form ideally in advance of a visit, but if that is not possible, then in the waiting room prior to seeing the provider.
Sample Agenda Setting Form
Patient Name: __________________________________
Hello. I’m excited to get to serve you today. Taking care of my patients is my joy, passion, and calling. My dream is to spend unlimited time with my patients. Unfortunately, government and insurance policies have created a system that limits most office visits to 15 minutes. I want you and I to get a lot done for you today. If we need to, I will setup a follow up visit to take care of the rest. Please, fill out this form to get us started. Thank you!
1) What are the two main things you would like us to focus on and get done for you today?
_____________________________________________________________________________
_____________________________________________________________________________
2) What are other things you would like us to take care of today (if there is time) or schedule a future visit (if there isn’t time):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Check all that apply:
- I have chest pain or tightness
- I need some prescriptions refilled
- I need a school or work excuse
- I need a referral to a specialist
- I need some forms filled out today
- I would like to get some help losing weight and staying healthy
- I feel depressed and would like some help
- I would like to get tested for sexually transmitted diseases
- Need some shots
Please answer the following questions.
Have you been to urgent care, emergency room or been hospitalized since your last office visit? YES / NO. If yes, where:
___________________________________________________________________________
Have you seen any specialists since your last office visit? YES / NO. If yes, please list them.
___________________________________________________________________________
Resources
Click to access 6-Patient-Provider-Agenda.pdf