Sign out
Overview
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 |
Date |
Results |
|---|---|---|
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 |
My reaction |
|---|---|
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? |
Reminder
Bring any records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.
Related Information
Credits
Current as of: April 30, 2024
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: April 30, 2024
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.
