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Home > Patient & Family Resources > Health Library > Regular Checkup for a Lifelong Condition
COVID-19 Info: Vaccines | Testing | Visitor Guidelines | Stats | More
IMPORTANT NOTICE: COVID-19 testing appointments are not available at Cone Health emergency departments or urgent care locations. Click here for testing options.
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
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