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?

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: _______