Print this form now to take with you to fill out during your doctor's appointment. In order to make sure you understand your condition and treatment, ask your doctor these questions and write down the answers to review when you are home.

1. What is the name of my problem?

   ---

2. What caused the problem?

   ---

   
   

   ---

3. Will I keep having this problem?

   ___ Yes___ No

4. How can I stop this problem from occurring again?

   ---

   
   

   ---

   
   

   ---

Treatment

1. Should I take any medications - which ones?

   ___ Yes___ No

   ---

2. What will the medication do?

   ---

   
   

   ---

3. How should I take the medication?

   ___ Morning___ Noon___ Night

   times/day times/week

   ---

4. Do you have anything written about how this medication works?

   ___ Yes___ No___ Available through pharmacist

5. Are there any side effects associated with this medication and are there any I should be watching for?

   ___ Yes___ No

   ---

   
   

   ---

6. When should I call you if these side effects occur?

   ___ Immediately ___ During office hours ___ Next Day ___ Tell you at next appointment.

7. If I stop taking the medication, what will happen?

   ---

   
   

   ---

8. Are there any foods or other drugs that I should not take while on this medication?

   ___ Yes___ No

   ---

   
   

   ---

9. Are there any other signs of symptoms that I should watch for and call you about?

   ___ Yes___ No

   ---

   
   

   ---

10. Do I need to limit any activities? How and which ones?

    ___ Yes___ No

    ---

    
    

    ---

11. Should this restrict my normal daily activities or will I be able to continue to go to work, do physical exercise, etc.?

    ___ Yes___ No

    ---

    
    

    ---

Lab and Diagnostic Tests

1. Will you need to do any lab or other diagnostic tests?

   ___ Yes___ No

   If so, which ones?

   ---

   
   

   ---

2. What will the tests tell you?

   ---

   
   

   ---

3. Will someone call me with the results or do I need to call the office?

   ___ Yes___ No___ Call the office myself

4. How soon will I get the results?

   ___ Tomorrow___ This week___ Next week

   Exact Date

Follow Up

1. Do I need to see a physician specialist?

   ___ Yes___ No

   Type of specialist:

2. When is my next return visit?

   Exact Date

3. Do you want me to call you to inform you of my progress?

   ___ Yes___ No

   When

4. Emergencies: How do I reach you in case of an emergency during daytime and after office hours?

   Daytime

   After Hours