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Inicio Centro de información Biblioteca del bienestar Appointment for a New Problem

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.

This information does not replace the advice of a doctor. Healthwise, Incorporated, 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. Learn how we develop our content.

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Divulgaciones

Los planes de seguro médico y dentales, tanto individuales como familiares, están asegurados por Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc. y Cigna HealthCare of North Carolina, Inc. El seguro de salud de grupo y los planes de beneficios de salud están asegurados o administrados por CHLIC, Connecticut General Life Insurance Company (CGLIC) o sus afiliados (consulta la lista de entidades legales que aseguran o administran HMO grupal, HMO dental y otros productos o servicios en tu estado). Los planes o pólizas de seguro para lesiones accidentales, enfermedades críticas y cuidado hospitalario son distribuidos exclusivamente por o a través de subsidiarias operativas de Cigna Corporation, son administrados por Cigna Health and Life Insurance Company y están asegurados por (i) Cigna Health and Life Insurance Company (Bloomfield, CT), (ii) Life Insurance Company of North America (“LINA”) (Philadelphia, PA) o (iii) New York Life Group Insurance Company of NY (“NYLGICNY”) (New York, NY), anteriormente llamada Cigna Life Insurance Company of New York. El nombre Cigna, logotipo y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. LINA y NYLGICNY no son afiliadas de Cigna.

Todas las políticas de seguros y los planes de beneficios grupales contienen exclusiones y limitaciones. Para conocer la disponibilidad, costos y detalles completos de la cobertura, comunícate con un agente autorizado o con un representante de ventas de Cigna. Este sitio web no está dirigido a los residentes de New Mexico.

Al seleccionar estos enlaces, saldrás de Cigna.com hacia otro sitio web que podría ser un sitio web externo a Cigna. Es posible que Cigna no controle el contenido ni los enlaces de los sitios web externos a Cigna. Información detallada