First Appointment

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.

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.