Problem/Goal Statement:

1. Description of Issue: • Write a 1-2 sentence summary of the symptom history or your experience. Or, a bulleted list: • Symptom, condition, sensation, or observation a. • Symptom, condition, sensation or observation b. • Symptom, condition, sensation or observation c. • Etc. Treatment Plan Summary Name/Patient Number/email/phone • Notes/Analysis: • Use this area to jot down notes of your conversation with your doctor or medical professional. • Bullet lists- or even visuals-can make it easier to remember what was said. • Another person can take notes to ensure accurate recollection. Current Symptoms: Pain Map Describe or Summarize your current experience or symptoms. If you have readings, measurements, numbers over a period of time, it’s helpful to condense them into a chart. Other visuals, such as pictures help to show your observations about what you are currently experiencing and why you are seeking medical services. Treatment Option(s): List the treatment options your medical provider has given you and any information you want to track about those options. Current Treatment Plan and Next Follow-up: List the steps you need to take next. Problem/Goal Statement: Clearly State or summarize either the problem you want to address, or what outcome or set of outcomes you want to achieve. You can use the visual model below to set some short-term and long-term objectives. Objectives Continuum: