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?

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2. What caused the problem?

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3. Will I keep having this problem?

   Yes No

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

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Treatment

1. Should I take any medications - which ones?

   Yes No

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2. What will the medication do?

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3. How should I take the medication?

   Morning Noon Night

   times/day times/week

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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

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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?

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

   Yes No

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

   Yes No

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

    Yes No

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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

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Lab and Diagnostic Tests

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

   Yes No

   If so, which ones?

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2. What will the tests tell you?

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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

In Addition...

1. (Your Additional Question Goes Here.)

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2. (Your Additional Question Goes Here.)

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