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
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
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
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?
Bring any records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.
Current as of: August 21, 2019
Author: Healthwise Staff
Medical Review: Catherine Devany Serio, PhD - Psychology, Behavioral Health
Adam Husney, MD - Family Medicine
To learn more about Healthwise, visit Healthwise.org.
© 1995-2020 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.