Healthwise
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Topic Contents
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 |
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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 problem or hospital | Details |
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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 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?
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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.
Related Information
Credits
Current as of: October 24, 2024
Author: Ignite Healthwise, LLC 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, 2024
Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.
This information does not replace the advice of a doctor. Ignite Healthwise, LLC disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use and Privacy Policy. Learn how we develop our content.
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