Medical Appointment Brief Template
Use with Prepare a One-Page Brief for a Medical Appointment.
Fill this in manually from your own current labels, health records and notes. A general-purpose chatbot is not needed.
Not for triage
If you are unsure whether a symptom or change can wait, use an official clinical or urgent-care route for your location. For immediate danger or signs of an emergency, contact local emergency services. Ask a pharmacist about medicine-specific questions. Do not ask a chatbot to decide urgency.
Before you start
Do not paste identifiable health information, documents, prescription labels or medication lists into a general-purpose AI service. Removing names does not make the material anonymous. Turning model training off does not separately control retention, history, human review, sharing, connected apps or legal access.
If your care provider or organization offers an explicitly approved protected tool, follow its rules for the exact data and purpose. Otherwise use this worksheet on paper or in an ordinary document.
Visit basics
- Date of appointment:
- What I want from this visit, in one sentence:
- My two or three most important questions:
Factual timeline
| Approximate date | What I noticed, in my words | Context or change | What I tried and what happened |
|---|---|---|---|
- Effect on work, school, sleep, mobility, eating, self-care or other activities:
- What worries me, clearly labelled as my concern rather than a diagnosis:
Medication, allergy and reaction list
Copy this manually from current labels, a pharmacy list or an official health record. Do not use memory, and do not ask AI to transcribe, complete, normalize or correct the list.
| Medication exactly as printed | Strength and instructions exactly as printed | How I actually take it | Source and date checked |
|---|---|---|---|
- Non-prescription medicines, vitamins and supplements:
- Allergies and previous adverse reactions:
- Conflicts between records to ask the pharmacist or care team to reconcile:
Access and communication
- Interpreter, accessibility, communication, transport or support-person need:
- Records, readings, forms or devices the service asked me to bring:
Questions, answers and follow-up
| My question | Clinician’s answer | Next action and owner | When |
|---|---|---|---|
- Who should I contact if the situation changes or I become worse?
Optional fictional formatting practice
Never replace the placeholders with real health, medication or identifying details in a general-purpose chatbot.
This is fictional practice, not a real patient's information. Format the
placeholder text below into the headings: visit goal, timeline, personal
priorities, questions, and blank follow-up fields. Do not diagnose, rank by
medical seriousness, infer missing facts, change medication information or
take actions. Keep every placeholder visibly fictional.
[FICTIONAL PLACEHOLDERS ONLY]
The instruction not to infer or act is not a security control. The safe-input rule keeps real health information out of the service.
Before the visit
- The brief came from my verified records and my own notes.
- I copied every medicine from a current source, not memory or AI.
- I marked conflicting records instead of resolving them myself.
- I put my most important questions near the top.
- I arranged communication or access support where relevant.
- I left space for answers, ownership and dates.