Next Visit Information

When you and your health care team such as your doctors, nurse, and pharmacist are working together, your health can only improve. Plan your next visit. Know what your goals are, or at least the questions that you want answered.

Basic Information

Today’s date (yyyy-mm-dd) : _____________ Birthday (yyyy-mm-dd): _______________ E-mail address: _____________________ First name: _________________________ Last name: _____________________________________ Address: _____________________________________________________________ City: ______________ Postal Code: _______________ Telephone # home: ___________________ Work _____________ Best time to call: ____________

Medications

Always bring a list of all your medications including doses to every physician visit. Complete the list below: Medication Dosage Reason for taking ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ ______________ _________ __________________________ How often do you forget to take your medication? ___ Never ___rarely ___ sometimes _____ frequently If you are having any side effects or you are not taking your pills properly do not adjust them on your own but discuss them with your physician or pharmacist: Allergies or Side Effects: _________________________________________________

Questions

Medical issues are becoming more and more complex. Most physician visits are brief. While not all issues may be addressed, having a list and setting priorities are important steps. Primary or main question: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Other questions that I would like addressed: ________________________________________________________________________ _________________________________________________________________ ________________________________________________________________________

Current Medical issues and Medical History

(Please check all that apply): __ loss of appetite __ failing vision __ nausea/vomiting __ difficulty swallowing __ diabetes type 1 __ diabetes type 2 __ leg pain when walking __ dizzy/fainting spells __ stroke __ heartburn __ thyroid disease __ bronchitis/chronic cough __ seizures __ asthma/wheezing __ shortness of breath __ gallbladder trouble __ headaches __ cancer __chest pain with activity __worsening chest pain __ muscle soreness/weakness __ jaundice/hepatitis __arthritis/rheumatism __ palpitations __ blood transfusions __ diarrhea/constipation __ back pain __ bloody or tarry stools __ blood in urine __ peptic ulcer __ AIDS/HIV __ sexual concerns __ swollen ankles __ osteoporosis __ gout __ sleep apnea __ sleep difficulty __ anemia/bruise easily __ weight loss/gain __ depression/anxiety __ suicidal Female patients – please complete Menstrual flow: __ regular __ irregular__ __ flushing/menopausal symptoms Date of last period _______

Key Measurements

The best way to treat a disease is to prevent it from happening. Blood Pressure ________ / _________ What is your cholesterol? _______ Minutes of activity per week: ______________ What is your blood sugar (A1C)? __________ Are you watching your diet: _______________ Weight: ________ lbs or _______ kg Are you a smoker? ______ Cigarettes per day: _____Quit date (yyyy-mm-dd): _______ Are there stresses in your life or are you depressed: ______ Do not take your health for granted. Prepare for your next physician visit. Keep a copy for your records and leave one for your physician’s chart. Do not be afraid to say to your doctor that you do not understand certain points of your health.

Emergencies

Call 911 for true emergencies or use a hospital’s Emergency Room (ER) service for emergencies like chest pain coming from your heart unrelieved by 3 sprays of Nitro taken 5 mins apart that lasts greater than 15 mins.

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