Complete this form if you are seeing this health professional for the first time. Although you may have to complete a similar form when you arrive at the office, completing this form will help you organize your thoughts and provide more complete information.

Complete Section 2 at the end of your appointment if you have a health problem that needs treatment.

Section 1: Current health and health history

Why did I make this appointment?

Am I having any symptoms? Describe them. If pain is one of my symptoms, include 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, divorce)?

Questions for women

Am I pregnant? Yes____ No____

When was my last menstrual period? _________

At what age did my menstrual cycles begin? _________

My cycles are: Regular____ Irregular ____

When was my last mammogram? _________

If the results were abnormal, explain:

• _________________________________
• _________________________________
• _________________________________

When was my last Pap smear? _________

If the results were abnormal, explain:

• _________________________________
• _________________________________
• _________________________________

When was I last screened for colon cancer (if I am older than 50)? _________

If the results were abnormal, explain:

• _________________________________
• _________________________________
• _________________________________

Questions for men

When was my last prostate examination (if I am older than 50 and younger than 75)? _________

If the results were abnormal, explain:

• _________________________________
• _________________________________
• _________________________________

When was I last screened for colon cancer (if I am over age 50)? _________

If the results were abnormal, explain:

• _________________________________
• _________________________________
• _________________________________

Immunization history

• Influenza Yes____ No____ Date last received _________
• Pneumococcal Yes____ No____ Date last received _________
• Tetanus (Td and Tdap) Yes____ No____ Date last received _________
• Hepatitis B Yes____ No____ Date last received _________
• Shingles Yes____ No____ Date last received _________
• Other _______________________ Date last recieved _________

Health history

Health problems. List your current health problems, such as poor eyesight or diabetes, and the name of the health professional you see for each problem.

• Health problem __________________________ Health professional __________________________
• Health problem __________________________ Health professional __________________________
• Health problem __________________________ Health professional __________________________

Hospitalizations. Provide information for each time you have been in the hospital. Include any surgeries you have had on an outpatient basis.

Date of when I was there _______________________________

• Why was I in the hospital? _______________________________
• Who was my doctor? _______________________________
• What hospital was I in? _______________________________

Date of when I was there _______________________________

• Why was I in the hospital? _______________________________
• Who was my doctor? _______________________________
• What hospital was I in? _______________________________

Date of when I was there _______________________________

• Why was I in the hospital? _______________________________
• Who was my doctor? _______________________________
• What hospital was I in? _______________________________

Allergies. Fill in the following information if you have allergies to medicines or other substances.

Medicine or other substance _______________________________. My reaction:

• _________________________________
• _________________________________
• _________________________________

Medicine or other substance _______________________________. My reaction:

• _________________________________
• _________________________________
• _________________________________

Medicine or other substance _______________________________. My reaction:

• _________________________________
• _________________________________
• _________________________________

Family history. List family members (parents, brothers, sisters, grandparents) who have or had the following major conditions.

Health condition	Relative (parent, brother, sister, grandparent)	Age, if living	Age at death	Comments
Heart problems
Kidney disease
Lung disease
Depression or other major mental health condition
Diabetes
Breast cancer
Colon cancer
Other cancer or inherited disease

Tobacco and alcohol use

Product (cigarettes, cigars, pipe, vape, or chewing tobacco)

• _________________________________
• _________________________________
• _________________________________

How much am I using now, or how much did I use before I quit?(for example, 1 pack of cigarettes a day or 1 cigar about once a week)

• _________________________________

How long has it been since I quit?

• _________________________________

Physical exercise

What type of exercise do I do? (for example, walking, jogging, stretching)

• _________________________________
• _________________________________
• _________________________________

How frequently do I exercise? (for example, 3 times a week) ___________________

How long do I exercise each time? (for example, 10 minutes, 30 minutes) ___________________

Personal preferences. Do I have any cultural, religious, or personal beliefs that may affect my treatment options? Describe them briefly:

• _________________________________
• _________________________________
• _________________________________

Stop here. By the end of your appointment, make sure you have answers to the questions in Section 2 if you need treatment for a health problem as the result of this visit.

Section 2: Treatment for this health problem and next steps

What is the diagnosis?

What does it mean in plain English?

What might happen next?

Do I need a medicine? Yes ___ No ___ If yes, fill in the following information.

• Name of medicine ____________________________
• How much and how often to take it ______________________
• What to watch for
  • _________________________________
  • _________________________________
  • _________________________________

Do I need surgery or another treatment? Yes ___ No ___ If yes, fill in the following information.

• Name of treatment ______________________
• Who will do it ______________________
• Where will it be done ______________________
• How to prepare for it
  • _________________________________
  • _________________________________
  • _________________________________

What are the risks and benefits of medicine, surgery, or other treatment? Fill in the following information about the treatment your health professional recommends for this condition.

• What are the chances that the treatment will work?
• What are the risks associated with the treatment?
• What might happen if I delay or avoid treatment?
• How soon will I see results of the treatment?
• What other treatment options are available?

Do I need a medical test or X-ray? Yes ___ No ___ If yes, fill in the following information.

• What is the name of the test? ______________________
• Will the test results change the treatment? If yes, explain:
  • _________________________________
  • _________________________________
  • _________________________________
• How do I get the test results? ______________________

What home treatment can I do? Ask the following questions about what you can do to help treat your condition.

What do I need to change? How?

• Eating: _________________________________
• Sleeping: _________________________________
• Exercise: _________________________________
• Other: _________________________________

What home treatment do I need to add? (for example, using a humidifier)

• _________________________________
• _________________________________
• _________________________________

Do I have concerns about being able to carry out my part of the treatment? Yes ___ No ___ If yes, discuss them with your health professional now.

• Where can I get more information about this problem or the treatment?
• How soon do I need to make a decision about getting a test or starting treatment?
• What signs and symptoms should I watch for?
• When should I call to report signs and symptoms?
• Is there a chance that someone else in my family might get the same condition?

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 for test results or to report how I am doing:

• Date _____________
• Time _____________

Return for an appointment:

• Date _____________
• Time _____________

Reminder

Bring to your appointment all your medicines or a list of all the medicines you are taking.