Previsit Checklist:

Please read the lists below and circle any items that are concerns, issues or desires.  Add additional items in the blanks provided.  Bring the checklist with you for your visit or send it.

List of Emotions:

Acceptance, Agitation, Alarm, Amusement, Anger, Angst, Anticipation, Apathy, Apprehension, Awe, Bitterness, Boredom, Calmness, Comfort, Contentment, Confidence, Courage, Depression, Disappointment, Discontentment, Disgust, Desire, Delight, Elation or Euphoria, Embarrassment, Envy, Ecstasy, Fear, Frustration, Glee, Gladness, Gratitude, Grief, Guilt, Hate, Happiness, Homesickness, Honour, Hope, Horror, Humility, Joy, Jealousy, Kindness, Loneliness, Love, Lust, Modesty, Nervousness, Negativity, Nostalgia, Pain, Patience, Peace, Phobia, Pity, Pride, Rage, Remorse, Sadness, Self-pity, Shame, Shyness, Sorrow, Shock, Surprise, Suspense, Terror, Unhappiness, Worry.  Other  _______________________________________________________

 

List of Values:

 

Achievement, Ambition, Appreciation, Believe In Yourself, Caring, Character, Compassion, Confidence, Courage, Courtesy, Dedication, Determination, Devotion, Encouragement, Excellence, Foresight, Forgiveness, Friendship, Generosity, Giving Back, Grace, Gratitude, Hard Work, Helping Others, Honesty, Hope, Humility, Ingenuity, Inspiration, Integrity, Laughter, Leadership, Learning, Listening, Live Life, Live Your Dreams, Love, Loyalty, Making A Difference, Motivation, Opportunity, Optimism, Overcoming, Patience, Peace, Perseverance, Persistence, Preparation, Reaching Out, Respect, Responsibility, Right Choices, Rising Above, Sacrifice, Sharing, Stewardship, Strength, Teaching By Example, Team Work, True Beauty, Trust, Unity, Vision, Volunteering.  Other  _____________________________________________________________

 

List of Symptoms:

Abdominal Problems, Ankle Problems, Back Problems, Breast Problems, Chest Problems, Cold and Flu, Cough, Diarrhea, Ear Problems, Elimination Problems, Emotional Problems, Eye Problems, Facial Problems ,Fatigue, Feeding Problems, Fever, Foot Problems, Genital Problems, Hair Loss, Hand/Wrist/Arm Problems, Headaches, Hearing Problems, Hip Problems, Knee Problems, Leg Problems, Limitations, Lower Back Pain, Mouth Problems, Menstrual Cycle Problems, Mental Problems, Nausea and Vomiting, Neck Problems, Pain, Shortness of Breath, Shoulder Problems, Skin Rashes and Other Changes, Throat Problems, Tooth Problems, Urination Problems, Weakness.  Other  _____________________________________________________