just put the date and under reason for visit what condition or disease that you were approved on as the reason and only as much of it that fits in the boxes. when you run out of boxes stop writing even if the word is cut off. dont change anything, list the conditon as they list it

for example for me it would be

09/22/2012 peripheral neuropathy
11/17/2012 asthma
1/20/2013 peripheral neuropathy

thats it. no need to list for medication or follow up or anything else just list the condition

if you have 1 condition that you were approved on you canlist last three visits in time period, if two, then last three pertaining to two and if three conditions, one visit for each condition.

hope this helps