Dr Yates Follow-Up Questionnaire
Please complete at least 24 hours before your follow-up appointment
DATE
/
Month
/
Day
Year
Date
Full Name
*
First and Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Current Age
Preferred Contact Telephone Number
*
Email Address
*
example@example.com
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Have you experienced any changes in your symptoms or health status of your primary complaints/concerns discussed during your previous appointments? If so, please describe those changes.
*
If no change, please respond as no change.
0/2000
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What changes discussed during your previous appointment have you been able to successfully adopt?
*
0/2000
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What challenges have made changes more difficult? If you have not made a change, what challenges have kept you from taking that change?
*
If no challenges, please indicate no challenges.
0/1200
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What sources have you consulted to learn more about your condition? Please list things like websites, podcasts, suggested readings, other individuals, etc.
*
If no sources, please indicate no sources.
0/600
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Please list your top 3 medical complaints/concerns
#1 medical complaint/concerns (if applicable)
0/300
#2 medical complaint/concerns (if applicable)
0/300
#3 medical complaint/concerns (if applicable)
0/300
Submit
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