The following checklists will help you prepare for and participate in your visit with your doctor. Provide as much information as possible to help your doctor accurately diagnose your problem. Ask questions when you do not understand what the doctor has told you.

Checklist 1: Prepare for Your Visit

1. What's your chief complaint? If you have pain, be prepared to describe it.
   
   

   Complaint	Description

   
   
2. Medications. Include prescriptions, herbal remedies, vitamins, and over-the-counter medications.
   
   

   Name	Dose	Frequency

   
   
3. Allergies. List medicines, foods, environmental sources, etc.
   
   
   
4. Other medical conditions.
   
   
   
5. Family Medical History.
   
   

   Relation	Alive/Deceased	Ailment

   
   
6. Lifestyle habits. Includes eating, drinking, sleeping, exercising habits.
   
   
   
7. Health concerns.
   
   
   
8. Pharmacist’s phone number and store location.
   
   

   Store Name	Store Location	Store Telephone #

Checklist 2: Actively Participate in the Visit

1. What do you think my diagnosis is? Ask for simple definitions of confusing medical terms.
   
   
   
2. Do I need any tests to rule-out or confirm my diagnosis?
   If so, what tests do I need?
   Where do I need to go to take the test(s)?
   How and when will I receive the test results?
   
   
   
3. How is my problem treated?
   How can it be prevented in the future?
   
   
   
4. Do I have treatment options?
   
   
   
5. When does the treatment begin and how long does it last?
   
   
   
6. Do I need to take any medicine?
   If so, what medication?
   How often do I take the medicine and for how long?
   What side effects should I be aware of?
   
   

   Medication Dose How long Side effects

   
   
7. When do I need to call or see you again?
   
   
   
8. How are expenses handled for this visit and tests?
   
   
   
9. Healthcare provider’s information.
   
   

   Healthcare Provider	Contact Hours	Telephone #

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