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Overview
Print this form and fill in Section 1 before your appointment.
Complete section 2 at the end of your appointment if you have a health problem that needs treatment.
Section 1
What questions or concerns do I want addressed during this appointment? |
My symptoms |
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Do I have any symptoms? Include how long I've have had them and what helps relieve them. If I have pain, describe where it is, how it feels, and how severe it is. |
If I have had these symptoms before, what helped then? |
Has there been a recent change in my normal routine (for example, sleeping, eating, recent death of a loved one, divorce)? |
Health problem or hospital |
Details |
|---|---|
Medicine or other substance |
My reaction |
|---|---|
Stop here. By the end of your appointment, make sure you have answers to the questions in Section 2.
Section 2
Summary of this appointment and next steps |
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What is the diagnosis? What does it mean in plain English? What might happen next? Do I need a medicine? Yes ___ No ___ If yes, fill in the following information. |
Name of medicine |
How much and how often to take it |
What to watch for |
|---|---|---|
Do I need surgery or another treatment? Yes ___ No ___ If yes, fill in the following information.
Name of treatment |
Who will do it |
Where it will be done and what to do to prepare for it |
|---|---|---|
What are the chances that the treatment will work? |
What are the risks associated with the treatment? |
What might happen if I delay or avoid treatment? |
How soon will I see results of the treatment? |
What other treatment options are available? |
What is the name of the test? |
Will the test results change the treatment? If yes, explain: |
How do I get the test results? |
What do I need to change? How?
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What home treatment do I need to add (for example, using a humidifier)? |
Where can I get more information about this problem or the treatment? |
How soon do I need to make a decision about getting a test or starting treatment? |
What signs and symptoms should I watch for? |
When should I call to report signs and symptoms? |
Is there a chance that someone else in my family might get the same condition? |
Check here if no contact is needed. ____ |
Call for test results or to report how I am doing: Date: ____________ Time: ____________ |
Return for an appointment: Date: ____________ Time: ____________ |
Reminder
Bring to your appointment all your medicines or a list of all the medicines you are taking.
Related Information
Credits
Current as of: October 24, 2023
Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.
Current as of: October 24, 2023
Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.
