Communication - Doctor

Doctor Visit Forms

     There are three main types of doctor’s appointments: acute visits, maintenance evaluations and follow-up appointments.  The acute visit is used when the patient has a medical problem and needs an immediate evaluation such as a cough or fever.  Maintenance visits are visits that do not require urgency and can be set up at the convenience of the doctor and the patient.  The annual physical exam is a common example of the maintenance visit. 

     Follow up visits are used when the health care provider needs to evaluate the effectiveness of a treatment or to monitor a chronic disease.  For example, when a patient is started on a new blood pressure medicine the doctor will schedule a follow-up visit to evaluate the effectiveness of the drug or look for any negative consequences of the drug. 

     The acute visit form will help you organize health care information when presenting with a new health care issue.  It includes a section to record instructions on treatment and follow-up with the health care provider.  The form is set up to become part of your health record, in section five.  

     The following is a list of steps to help you fill out the acute visit form.

1. Record the doctor’s name, the date and a brief description of the problems.
2. List your specific symptom and any describing factors.  See acute visit describing information for a listing of common symptoms and important describing information that will help your doctor determine the origin of your problem. 
3. Bring the form to the doctor appointment and record the doctor’s diagnosis.
4. Record the names of any medications that the doctor prescribes and ask: a) how to take it/how long to take it b) side effects c) any follow up required.
5. Record any other treatments ordered.
6. Record any testing the doctor wants to perform including radiology or laboratory work.
7. Most importantly record what type of follow up is necessary.  It is important to specifically ask when you should be seen back in the office, when to call the office and what information you can gather about this problem that will help your evaluation.  For example, daily weights are helpful in evaluating response to treatment of congestive heart failure.  

     The follow up visit form helps you relate information to the doctor after a specific problem has been diagnosed.  It is a place for you to record information that the doctor needs to track how your disease is progressing or how you are responding to treatment.   This section is the most variable and may include a variety of things.  Many things being evaluated for may be better tracked with specific chronic disease forms (for more information see Chronic Disease Guide: How to Prevent and Treat Common Chronic Diseases).  Anytime you are seen for an acute visit you should ask, “What information can I gather about this problem that will help your evaluation”.  This form is a place to gather that information.

     The annual form is a place for you to record information that will help your doctor give you a comprehensive evaluation.  The first section is a place to list any changes over the last year including medical illness, surgeries, exercise, alcohol consumption and smoking.  The form includes a section for you to record any symptoms you are having. 

     Social functioning is important to the overall health of the patient.  Communicating any social changes to your health care provider at the annual appointment will help evaluate your overall health.  The annual form includes some questions that will help the doctor screen you for depression.  

       For older adults it also provides a place for you to record how you are functioning.  The form provides a list of activities and asks you to rate how well you are functioning with these specific tasks.  Activities listed include feeding, toileting, dressing and bathing (to name a few) and a box for you to check how well you are doing.  Are you able to perform these tasks independently, with some help, with heavy assistance or do you completely rely on someone to do this for you? 

     The annual form concludes with a list of questions that you should ask your health care provider.  By asking these questions you will assure that you doctor evaluates all aspects of good preventative health care.  To be more specific, bring along the preventative health care worksheet and go through each item on the list. 

     The last form is the question form.  This is a form for you to record a list of questions you want your health care provider to answer.  Report the questions in order of importance.  The most important question that you want answered should be number one.  Realize that you may not get to all of you questions during the office visit.  Make one copy for you and one for your health care provider.