Mito Discovery Alliance patient visit summary template

Use this as a simple one-page note for a clinic visit. Write down what changed, what you want to ask, and what you want to remember so the visit starts with the most important points. Bringing a current summary can help keep questions, changes, and next steps organized, and it can make it easier to notice what changed since the last time you wrote things down. If you use Mito Map, you can bring the current summary or note what changed since your last update. It is not medical advice, a diagnosis, or a treatment plan.
Writing the note ahead of time can make the visit feel more organized and less rushed.

What changed since the last visit?
- What symptoms, questions, or care changes do you want the clinic to know about?
- What is new, worse, better, or still unclear?

What do you want to ask?
- What questions do you want answered at the next visit?
- Which questions should wait for the care team rather than being answered on a public form?

What do you want to remember?
- Which summary points, dates, or next steps should stay with you?
- What would you like to bring back in your own words?

What should stay private?
- Do not paste raw charts, lab files, or genetic reports into public forms.
- Keep detailed records, consent choices, and patient-level follow-up in Mito Map or the approved care workflow if you use them.

First 30 days
- Finish your account setup and choose the program that fits you best.
- Save this note or bring it back when symptoms, care, or goals change.
- Review the summary preview so you know what Mito Map can organize before you share more.
- Send feedback if any step felt confusing, so onboarding stays clear for the next person.

Where to go next
- Clinician page: /clinicians
- FAQ: /faq
- Evidence library: /publications

MDA is educational and does not replace clinical judgment, diagnosis, treatment, or urgent care.