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?
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My symptoms |
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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 |
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Allergies
Fill in the following information if you have allergies to medicines or other substances. Medicine or other substance | My reaction |
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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 |
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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 |
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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 |
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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:
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What home treatment do I need to add (for example, using a humidifier)?
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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
