Medical Appointment Summary Sheet for FND

For people living with Functional Neurological Disorder

This printable is designed to support clearer communication during medical appointments. It is intentionally brief and structured so it can be shared, printed, or referenced during visits.

Patient Information

• Name:
• Date of birth:
• Appointment date:
• Provider or clinic:

FND Diagnosis

• Diagnosis: Functional Neurological Disorder
• Diagnosed by (if applicable):
• Year of diagnosis (if applicable):

Primary Reason for This Appointment

(One main purpose)

Current Functional Concerns

(How symptoms affect daily function)

Symptom Patterns or Changes

(Recent changes or notable patterns)

Relevant Medical History

(Only what is directly relevant to this visit)

Current Supports or Treatments

(Medications, therapies, aids, or supports in use)

Questions or Topics to Discuss

(Prioritize what matters most)

Notes From the Appointment

(To complete during or after the visit)

Next Steps and Follow-Up

(Tests, referrals, timelines, or instructions)

Additional Notes

(Optional)

About This Sheet

This summary sheet is intended to support clearer, more focused medical conversations. It does not replace clinical documentation or medical records.

People living with FND may experience symptom fluctuation, fatigue, or communication difficulty during appointments. Using a written summary can help reduce cognitive load and support more effective healthcare interactions.