COVID-19 Information: Vaccine | Testing | Self-assessment | Patient & Visitor Safety | Visitor Policy
Emergency Room Wait Times
Home > Living Well > Health Library > 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:
February 11, 2021
Author: Healthwise StaffMedical Review: Catherine D. Serio PhD - Behavioral HealthAdam Husney MD - Family Medicine
Current as of: February 11, 2021
Author: Healthwise Staff
Medical Review:Catherine D. Serio PhD - Behavioral Health & Adam Husney MD - Family Medicine
To learn more about Healthwise, visit Healthwise.org.
© 1995-2021 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.
Disclaimer: The information contained in this website, and its associated websites, is provided as a benefit to the local community, and the Internet community in general; it does not constitute medical advice. We try to provide quality information, but we make no claims, promises or guarantees about the accuracy, completeness, or adequacy of the information contained in or linked to this website and its associated sites. As medical advice must be tailored to the specific circumstances of each patient and healthcare is constantly changing, nothing provided herein should be used as a substitute for the advice of a competent physician. Furthermore, in providing this service, Adventist HealthCare does not condone or support all of the content covered in this site. As an Adventist health care organization, Adventist HealthCare acts in accordance with the ethical and religious directives for Adventist health care services.
Find an Adventist HealthCare affiliated doctor by calling our FREE physician referral service at 800-642-0101 or by searching our online physician directory.
Set Your Location
Setting your location helps us to show you nearby providers and locations based on your healthcare needs.