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Use this form if your doctor recommends a special treatment, such as radiation or physical therapy.
What is the name of the treatment?
Why do I need this treatment?
What might happen if I delay or avoid this treatment?
Are there any other treatment options? If so, describe them:
What is the next step if this treatment doesn't work?
How much does the treatment cost? How can I find out?
Are there other costs to the treatment, such as equipment or therapy?
What kind of preparation is needed for this treatment?
Where will the treatment be done (hospital or other location)?
How is the treatment done?
Is the treatment painful?
Will the treatment be done only once or will it be repeated?
How successful is this treatment?
What are the risks associated with this treatment?
Who will do the treatment and how much experience does the doctor have doing this treatment?
What effects are expected after the treatment?
What complications might develop (both immediate and long-term)?
Does my doctor recommend that I see another health professional? If yes:
Name __________________ Address ___________________ Phone number _____________
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