regular checkup for a lifelong condition
overview
print this form and fill in the following information if this is a regularly scheduled appointment with your health professional.
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. |
has there been a recent change in my normal routine (for example, sleeping, eating, recent death of a loved one, or divorce)? yes ___ no ___ if yes, describe briefly. |
have i been diagnosed with any new disease or condition? yes ___ no ___ if yes, fill in the following information.
condition or disease | health professional who diagnosed the condition | what was the prescribed treatment? |
|---|---|---|
have i had any recent medical tests (blood, urine, x-rays, or other tests) that this health professional did not order? yes ___ no ___ if yes, fill in the following information:
name of test | date | results |
|---|---|---|
am i taking any prescription or over-the-counter medicines that my health professional is not aware of? yes ___ no ___ if yes, fill in the following information.
name of medicine | why am i taking it? |
|---|---|
do i have any new allergies to medicines, foods, or other substances? yes ___ no ___ if yes, fill in the following information.
medicine or substance | my reaction |
|---|---|
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? |
reminder
bring any records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.
credits
current as of: august 6, 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: august 6, 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.
