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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.

Credits

Current as of: March 9, 2022

Author: Healthwise Staff
Medical Review:
Catherine D. Serio PhD - Behavioral Health
Adam Husney MD - Family Medicine

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