appointment for a new problem
overview
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.
section 1
what questions or concerns do i want addressed during this appointment? |
my symptoms |
|---|
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 | details |
|---|---|
medicine or other substance | my reaction |
|---|---|
stop here. by the end of your appointment, make sure you have answers to the questions in section 2.
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: date: ____________ time: ____________ | return for an appointment: date: ____________ time: ____________ |
reminder
bring to your appointment all your medicines or a list of all the medicines you are taking.
credits
current as of: october 24, 2023
author: healthwise 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: october 24, 2023
author: healthwise staff
clinical review board
all healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.
