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
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
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
- Influenza Yes____ No____ Date last received _________
- Pneumococcal Yes____ No____ Date last received _________
- Tetanus (Td and Tdap) Yes____ No____ Date last received _________
- Hepatitis B Yes____ No____ Date last received _________
- Shingles Yes____ No____ Date last received _________
- Other _______________________ Date last recieved _________
Health history
Health problems. List 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 __________________________
- Health problem __________________________ Health professional __________________________
- Health problem __________________________ Health professional __________________________
Hospitalizations. Provide information for each time you have been in the hospital. Include any surgeries you have had on an outpatient basis.
Date of when I was there _______________________________
- Why was I in the hospital? _______________________________
- Who was my doctor? _______________________________
- What hospital was I in? _______________________________
Date of when I was there _______________________________
- Why was I in the hospital? _______________________________
- Who was my doctor? _______________________________
- What hospital was I in? _______________________________
Date of when I was there _______________________________
- 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:
- _________________________________
- _________________________________
- _________________________________
Medicine or other substance _______________________________. My reaction:
- _________________________________
- _________________________________
- _________________________________
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, cigars, pipe, vape, 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:
- _________________________________
- _________________________________
- _________________________________
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.
- 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 will it be done ______________________
- How 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)
- _________________________________
- _________________________________
- _________________________________
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:
- 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.