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Visit Tracking Sheet

Confidential document · internal use only
Date
Start time
End time
Type of visit
Location
Sheet no.
Person supported · Permanent information
Full name
Date of birth
Address
Phone
GP / family doctor
Permanent notes (allergies, usual treatments, important habits, points of attention)
Visit objectives
Medical accompaniment
Administrative matter
Digital assistance
Support / presence
Other:
Summary & observations of the visit
Appointments & ongoing matters
Date / Time
Subject (doctor, agency, matter…)
To do / bring
Status
Medication & treatments (checks, renewals, adherence)
Prescription to renew
Medication to buy
Treatment checked
Note:
Administrative tasks
Documents to gather / sign
Letter to send / expected reply
Online task to complete
Other:
General state & important observations
Mood:
Physical state:
Concerns raised:
Emergency contacts & key information (keep on this sheet)
Next steps & next visit
Next visit planned
Time
Purpose of next visit
Florian Lallier · Trusted Companion · +33 6 06 43 83 53 · lallierflorian@gmail.com
Châteauroux & Centre-Val de Loire · Art. L1111-6 of the French Public Health Code
Confidential
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