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Print this form and fill in the following information if this is a regularly scheduled appointment with your health professional.
What questions or concerns do I want addressed during this appointment?
Do I have any new symptoms? Yes ___ No ___ If yes, include how long I have had them and what helps relieve them. If I have pain, describe where it is, how it feels, and how severe it is.
Has there been a recent change in my normal routine (for example, sleeping, eating, recent death of a loved one, or divorce)? Yes ___ No ___ If yes, describe briefly.
Have I been diagnosed with any new disease or condition? Yes ___ No ___ If yes, fill in the following information.
Condition or disease
Health professional who diagnosed the condition
What was the prescribed treatment?
Have I had any recent medical tests (blood, urine, X-rays, or other tests) that this health professional did not order? Yes ___ No ___ If yes, fill in the following information:
Name of test
Am I taking any prescription or over-the-counter medicines that my health professional is not aware of? Yes ___ No ___ If yes, fill in the following information.
Name of medicine
Why am I taking it?
Do I have any new allergies to medicines, foods, or other substances? Yes ___ No ___ If yes, fill in the following information.
Medicine or substance
Have I had any difficulty carrying out my treatment for this condition? Yes ___ No ___ If yes, describe briefly:
Have I had any recent stresses that may affect my ability to care for the condition I have? Yes ___ No ___ If yes, describe briefly:
Do I need any special written information or instructions to help me care for the disease or condition I have, such as instructions about monitoring my blood sugar if I have diabetes? Yes ___ No ___
Are there any new treatments or tests for this condition?
What are the benefits and risks of the new treatments or tests?
What could happen if I choose not to have the new treatment or test?
Bring any records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.
Current as of:
March 9, 2022
Author: Healthwise StaffMedical Review: Catherine D. Serio PhD - Behavioral HealthAdam Husney MD - Family Medicine
Current as of: March 9, 2022
Catherine D. Serio PhD - Behavioral Health & Adam Husney MD - Family Medicine
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