Reason for Visit - Patient Questionnaire : Security Crossroads Medical Center

When you visit the physician's office there is a lot of information to share between you and your doctor in a short amount of time. It's easy to forget important questions or details that your doctor needs to know. This questionnaire is designed to help you get the most from your visit so you can feel your best.

Take a few minutes to fill out this form, print it, and take it with you to the physician's office.
Tip: There are only 5 lines available per question, so summarize information as much as possible. If you type more than 5 lines it won't show on the printout.

IMPORTANT : The information you entered is not saved to protect your privacy. Please print this page after entering the data so you don't lose your information.

Security Crossroads Medical Center. 2 East Rolling Crossroads #159, Catonsville MD 21228.

410-747-5888 Fax: 410-747-9648. www.securitycrossroads.com

Encounter Form

Your Name: 
Your birth date: 
Date of visit: 

Reason for your visit:

When did the problem start?

Has the problem improved or worsened? 

What makes the problem worse?

How have you tried to treat your condition?

List any medicines you've taken for the problem.

Are there any other issues that we need to address ?

Do you need any referrals ? Do you have to call your health plan to change your PCP ?

IMPORTANT : The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.


Click here to to return to the Appointments page.