Patient Education

Heart Health Library

Our Health Library 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 heart health. Our providers may not see and/or treat all topics found herein.

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.

Related Information

Credits

Current as of: April 30, 2024

Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

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Related Information

Current as of: April 30, 2024

Author: Ignite Healthwise, LLC Staff

Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.