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
Health information
|
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 conditions or diseases
Do I have any health problems? Have I ever been hospitalized?
|
Health problem or hospital
|
Details
|
|
|
|
|
|
|
|
|
Allergies
Fill in the following information if you have allergies to medicines or other substances.
|
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 risks and benefits of medicine, surgery, or other treatment? Fill in the following information about the treatment your health professional recommends for this condition.
|
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?
|
Do I need a medical test or X-ray? Yes ___ No ___ If yes, fill in the following information.
|
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 home treatment can I do? Ask the following questions about what you can do to help treat your condition.
|
What do I need to change? How?
- Eating:
- Sleeping:
- Exercise:
- Other:
|
|
What home treatment do I need to add (for example, using a humidifier)?
|
I have concerns about being able to carry out my part of the treatment. Yes ___ No ___ If yes, discuss them with your health professional now.
|
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?
|
When should I contact my health professional?.
|
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
Current as of: October 24, 2023
402-371-4880