Skip to main navigation
Skip to main content
Skip to footer
For
Medicare
For
Providers
For
Brokers
For
Employers
Español
For Individuals & Families:
For Individuals & Families
Medical
Dental
Other Supplemental
Explore coverage through work
How to Buy Health Insurance
Types of Dental Insurance
Open Enrollment vs. Special Enrollment
See all topics
Shop for Medicare plans
Member Guide
Find a Doctor
Log in to myCigna
Home
Knowledge Center
Wellness Library
Regular Checkup for a Lifelong Condition
Regular Checkup for a Lifelong Condition
Overview
Print this form and fill in the following information if this is a regularly scheduled appointment with your health professional.
|
What questions or concerns do I want addressed during this appointment?
|
|
Do I have any new symptoms? Yes ___ No ___ If yes, include how long I have had them and what helps relieve them. If I have pain, describe 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, or divorce)? Yes ___ No ___ If yes, describe briefly.
|
Have I been diagnosed with any new disease or condition? Yes ___ No ___ If yes, fill in the following information.
|
Condition or disease
|
Health professional who diagnosed the condition
|
What was the prescribed treatment?
|
|
|
|
|
|
|
Have I had any recent medical tests (blood, urine, X-rays, or other tests) that this health professional did not order? Yes ___ No ___ If yes, fill in the following information:
|
Name of test
|
Date
|
Results
|
|
|
|
|
|
|
Am I taking any prescription or over-the-counter medicines that my health professional is not aware of? Yes ___ No ___ If yes, fill in the following information.
|
Name of medicine
|
Why am I taking it?
|
|
|
Do I have any new allergies to medicines, foods, or other substances? Yes ___ No ___ If yes, fill in the following information.
|
Medicine or substance
|
My reaction
|
|
|
Treatment issues
|
Have I had any difficulty carrying out my treatment for this condition? Yes ___ No ___ If yes, describe briefly:
|
|
Have I had any recent stresses that may affect my ability to care for the condition I have? Yes ___ No ___ If yes, describe briefly:
|
|
Do I need any special written information or instructions to help me care for the disease or condition I have, such as instructions about monitoring my blood sugar if I have diabetes? Yes ___ No ___
|
|
Are there any new treatments or tests for this condition?
What are the benefits and risks of the new treatments or tests?
What could happen if I choose not to have the new treatment or test?
|
Reminder
Bring any records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.
Current as of: April 30, 2024
Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Ignite Healthwise, LLC 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. Learn how we develop our content.
To learn more about Ignite Healthwise, LLC, visit webmdignite.com.
© 2024-2025 Ignite Healthwise, LLC.
Related Links
Follow-Up Appointment
Regular Checkup for a Child
Your Family Medical History
Appointment for a New Problem
First Appointment
<cipublic-spinner variant="large"><span>Loading…</span></cipublic-spinner>