Answer the following questions before and during your appointment to follow up on a health problem.

• What health problem is the reason for this return appointment?
  • _________________________________________________________________
  • _________________________________________________________________
  • _________________________________________________________________
• 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.
  • _________________________________________________________________
  • _________________________________________________________________
  • _________________________________________________________________
• 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?
  • _________________________________________________________________
  • _________________________________________________________________
  • _________________________________________________________________

What signs and symptoms should I watch for?

• _________________________________________________________________
• _________________________________________________________________
• _________________________________________________________________

When should I call to report signs and symptoms?

• _________________________________________________________________
• _________________________________________________________________
• _________________________________________________________________

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 to find out test results or to report how I am doing:

Date: _______ Time: _______

Return for an appointment:

Date: _______ Time: _______

Reminder

Bring all the records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.