Overview
Print this page and fill in the following information before and during your appointment to follow up on a health problem.
Concerns
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What health problem is the reason for this return appointment?
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What questions or concerns do I want addressed during this appointment?
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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.
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Treatment issues
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Have I had any difficulty carrying out my treatment for this condition? Yes ___ No ___ If yes, describe briefly:
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Have I had any recent stresses that may affect my ability to care for the condition I have? Yes ___ No ___ If yes, describe briefly:
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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 ___
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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?
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Follow-up
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What signs and symptoms should I watch for?
When should I call to report signs and symptoms?
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When should I contact my health professional? Fill in the appropriate box below with the date and time, if needed.
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Check here if no contact is needed.
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Call to find out test results or to report how I am doing:
Date: _______ Time: _______
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Return for an appointment:
Date: _______ Time: _______
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Reminder
Bring all the records you have been keeping since your last visit, such as a blood sugar record if you have diabetes.
Credits
Current as of:
February 27, 2023
Author: Healthwise Staff
Medical Review:
Catherine D. Serio PhD - Behavioral Health
Adam Husney MD - Family Medicine
