Healthwise

Our Health Library information does not replace the advice of a doctor. Please be advised that this information is made available to assist our patients to learn more about their health. Our providers may not see and/or treat all topics found herein.

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

Due to the threat of the COVID-19 (Coronavirus), we are taking precautionary measures to protect our staff and patients. We are implementing a temporary NO VISITOR policy at this time. Only patients or patients and their guardians will be allowed into the office. Please note, this is not to inconvenience anyone! The virus is a very real threat and it is essential that we stay healthy in order to provide needed care for our patients. If you are sick, we ask that you CALL the office to speak with a nurse before you come in. The nurse will provide specific instructions for you. Please DO NOT enter the office if you are sick (upper respiratory symptoms, fever, cough, or flu like symptoms). We are closely monitoring the situation and will update you as circumstances change. Thank you for your understanding!!