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.
What questions or concerns do I want addressed during this appointment?
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 conditions or diseases
Do I have any health problems? Have I ever been hospitalized?
Health problem or hospital
Fill in the following information if you have allergies to medicines or other substances.
Medicine or other substance
Stop here. By the end of your appointment, make sure you have answers to the questions in Section 2.
Summary of this appointment and next steps
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 risks and benefits of medicine, surgery, or other treatment? Fill in the following information about the treatment your health professional recommends for this condition.
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?
Do I need a medical test or X-ray? Yes ___ No ___ If yes, fill in the following information.
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 home treatment can I do? Ask the following questions about what you can do to help treat your condition.
What do I need to change? How?
What home treatment do I need to add (for example, using a humidifier)?
I have concerns about being able to carry out my part of the treatment. Yes ___ No ___ If yes, discuss them with your health professional now.
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?
When should I contact my health professional?.
Check here if no contact is needed.
Call for test results or to report how I am doing:
Return for an appointment:
Bring to your appointment all your medicines or a list of all the medicines you are taking.
Current as of: October 6, 2021
Author: Healthwise Staff
Catherine D. Serio PhD - Behavioral Health
Adam Husney MD - Family Medicine