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NAME: DATE: PROVIDER: THINGS I WANT TO REMEMBER What are the most important things I would like to talk about at my visit today? (provider: check if discussed) 1. 2. 3. Anything else: Examples: Symptoms

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What is things i dont want?

Things you do not want are items or actions that you wish to avoid or not have.

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You can fill out things you do not want by making a list of items or actions that you wish to avoid or not have.

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