Overview
Complete this form if you are seeing this health professional for the first time. Although you may have to complete a similar form when you arrive at the office, completing this form will help you organize your thoughts and provide more complete information.
Complete Section 2 at the end of your appointment if you have a health problem that needs treatment.
Section 1: Current health and health history
Why did I make this appointment?
Am I having any symptoms? Describe them. If pain is one of my symptoms, include 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, divorce)?
Questions for women Questions for women to ask |
|---|
Am I pregnant? Yes____ No____ When was my last menstrual period? _____________ |
At what age did my menstrual cycles begin? _________ My cycles are: Regular____ Irregular ____ |
When was my last mammogram? ___________ If the results were abnormal, explain: |
When was my last Pap smear? __________ If the results were abnormal, explain: |
When was I last screened for colon cancer (if I am older than 50)? ________________ If the results were abnormal, explain:
|
Questions for menQuestions for men to ask |
|---|
| When was my last prostate examination (if I am older than 50 and younger than 75)? ______________ If the results were abnormal, explain:
|
When was I last screened for colon cancer (if I am over age 50)? _____________ If the results were abnormal, explain:
|
Immunization history
ImmunizationsImmunization | Date last received |
|---|
Influenza |
|
Pneumococcal |
|
Tetanus (Td and Tdap) |
|
Hepatitis B |
|
Shingles |
|
Other |
|
Health history
Health problems
Fill in your current health problems, such as poor eyesight or diabetes, and the name of the health professional you see for each problem. Health problem | Health professional |
|---|
|
|
|
|
|
|
Hospitalizations
Fill in the information for each time you have been in the hospital. Include any surgeries you have had on an outpatient basis. When was I there? (date or year) | Why was I in the hospital? | Who was my doctor? | What hospital was I in? |
|---|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Allergies
Fill in the following information if you have allergies to medicines or other substances. Medicine or other substance | My reaction |
|---|
|
|
|
|
|
|
Family history
List family members (parents, brothers, sisters, grandparents) who have or had the following major conditions. Health condition | Relative (parent, brother, sister, grandparent) | Age, if living | Age at death | Comments |
|---|
Heart problems |
|
|
|
|
Kidney disease |
|
|
|
|
Lung disease |
|
|
|
|
Depression or other major mental health condition |
|
|
|
|
Diabetes |
|
|
|
|
Breast cancer |
|
|
|
|
Colon cancer |
|
|
|
|
Other cancer or inherited disease |
|
|
|
|
Tobacco and alcohol useProduct (cigarettes, pipe, cigars, or chewing tobacco) | How much am I using now, or how much did I use before I quit?(for example, 1 pack of cigarettes a day or 1 cigar about once a week) | How long has it been since I quit? |
|---|
|
|
|
|
|
|
|
|
|
|
|
|
Physical exercise What type of exercise do I do? (for example, walking, jogging, stretching) | How frequently do I exercise? (for example, 3 times a week) | How long do I exercise each time?(for example, 10 minutes, 30 minutes) |
|---|
|
|
|
|
|
|
Personal preferencesDo I have any cultural, religious, or personal beliefs that may affect my treatment options? Describe them briefly: |
|---|
|
What other concerns do I have?
|
Stop here. By the end of your appointment, make sure you have answers to the questions in Section 2 if you need treatment for a health problem as the result of this visit.
Section 2: Treatment for this health problem 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.
MedicinesName 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.
Surgery or another treatmentName 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. Questions to ask |
|---|
What do I need to change? How? - Eating:
- Sleeping:
- Exercise:
- Other:
What home treatment do I need to add? (for example, using a humidifier)
|
Do 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?
Fill in the appropriate box below with the date and time, if needed. Check here if no contact is needed. | Call for test results or to report how I am doing: | Return for an appointment: |
|---|
____ | Date: ____ Time: ____ | Date: ____ Time: ____ |
Reminder
Bring to your appointment all your medicines or a list of all the medicines you are taking.
