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 men

Questions 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

Immunizations

Immunization	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 use

Product (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 preferences

Do 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.

Medicines

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.

Surgery or another treatment

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.

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.