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Answer the following questions before and during your appointment to follow up on a health problem.
What health problem is the reason for this return appointment?
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.
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?
What signs and symptoms should I watch for?
When should I call to report signs and symptoms?
Check here if no contact is needed.
Call to find out test results or to report how I am doing:
Date: _______ Time: _______
Return for an appointment:
Bring all the records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.
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