IT HAS COME TO OUR ATTENTION THAT YOU HAVE A HEALTH CONCERN IN THE FOLLOWING AREA. PLEASE CALL YOUR HEALTH CARE PROVIDER AS SOON AS POSSIBLE TO SCHEDULE AN APPOINTMENT FOR A CONSULTATION AND CHECK-UP.

__________________ CHOLESTEROL

__________________ BLOOD PRESSURE

__________________ DIZZINESS/ BLURRED VISION

__________________ RESPIRATORY DISTRESS

__________________ JOINT PAIN

__________________ MUSCULAR PAIN

__________________ CHEST PAIN

__________________ OTHER

I GIVE MY PERMISSION FOR YOU TO CONTACT MY HEALTH CARE PROVIDER ABOUT THE ABOVE MENTIONED SYMPTOM.

NAME____________________________________________________

PROVIDER________________________________________________

PHONE ___________________________________________________

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