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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 problem or hospital
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 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?
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:
Return for an appointment:
Bring to your appointment all your medicines or a list of all the medicines you are taking.
ByHealthwise StaffPrimary Medical Reviewer Catherine Devany Serio, PhD - Psychology, Behavioral Health Adam Husney, MD - Family Medicine
Current as ofMarch 29, 2018
Current as of:
March 29, 2018
Catherine Devany Serio, PhD - Psychology, Behavioral Health & Adam Husney, MD - Family Medicine