These are items that are not critical, i.e. immediate answer is not required. The top 3 items (previous page) are those you want answer for answers immediately.

Question List To Give To Doctor(s) 

Date:____________________________
Doctor:____________________________
Address:___________________________
____________________________
____________________________
Patient:____________________________ 
Address:___________________________
____________________________
____________________________
Tel Number: Area Code ( ) _____________
If applicable, spouse/caregiver contact and telephone number:
_________________________________________

Dear Doctor (fill in)

The following is a list of questions that I would like you to answer. If you can't answer them all today, (or on my visit ), then I would appreciate your getting back to me within the (fill in number of days) 
with the answers:

Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________

Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________

Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________

Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________

These issues are of importance to me Dr. (fill in) and your response will be greatly appreciated.

Respectfully,

(fill in your name/sign