- Review all of the questions on the checklist.
- Ask for a copy of a Patient Wellness Handout and have your provider review it with you. The Patient Wellness Handout is a document available at your health care facility that provides useful information about your health.
- Discuss any health conditions you have had. You indicated you wish to discuss the following: Basic information.
Do I need a flu shot?
(Be sure to tell your provider if you got a flu shot somewhere else, like the local Wal-Mart.)
Do I need a pneumonia shot?
(Be sure to tell your provider if you got a pneumonia shot somewhere else, like the local Wal-Mart.)
Does my newborn child need any shots? Do you have a vaccination schedule?
(Be sure to tell your provider if your child has received vaccinations somewhere else, like the hospital.)
Medicines I currently take
Prescriptions I currently take:
Herbal medicines I currently take:
Traditional medicines I currently take:
Over the counter medicines I currently take:
Could these cause problems with my other medicines?
Allergies to medicines
I am allergic to the following medicines:
I am allergic to the following vaccines:
Could that present a problem?
Breast Cancer Screening (Mammogram)
Talk with your provider about when to begin your regular mammography screening. Most organizations recommend that women begin their mammography screening at age 40.
What is a mammogram? Will the mammogram hurt?
Do I have to have a mammogram every year?
What are the benefits of beginning my mammogram screening at age 40?
What can affect my mammogram? How long will it take to get my results?
Can I perform a self examination? How accurate is it?
Cervical Cancer Screening (Pap Smear)
Women that are age 21-64 should have a Pap Smear at least every two years. Ask your provider what is best for you.
What is a Pap Test (Smear)? Will I always need to have regular pap tests?
I have had a hysterectomy. Do I still need to have a PAP?
What can affect my pap test? How long will it take to get my results?
How can I reduce my chances of getting cervical cancer?
Colorectal Cancer Screening
Colorectal cancer screening is recommended for average-risk men and women beginning at age 50. The following test(s) are recommended by the United States Preventive Services Task Force: Colonoscopy (once every 10 years), take home Fecal Occult Blood Test or Fecal Immunochemical Test (once a year) and Flexible Sigmoidoscopy (once every 5 years).
Will any of these tests be uncomfortable or painful? How long will it take to get my results?
What screening tests do you recommend for me? Why?
My family has a history of colorectal cancer; do I have a higher risk for colorectal cancer?
What happens next if I have a positive colorectal cancer screening test? Will I need a colonoscopy?
If I choose to do the screening with FOBT or FIT, why does the test need to be done at home and not while at the clinic?
Could this affect my health? How often should I be screened for these?
Tests or shots in other facilities
Since my last visit, I received the following treatments at another health care facility:
When it comes to exercise,
I exercise about days a week.
Normally when I exercise, I exercise about minutes. Is this enough?
Alcohol and Other Substances
On average, how many days per week do you have a drink of alcohol? A drink is one bottle of beer, one glass of wine, one wine cooler, or one shot of hard liquor (like whiskey, scotch, gin or vodka).
When I drink, I usually have about
What are the most number of drinks you have had at one time in the past month?
Is there something I can do to help me drink less?
I sometimes use drugs like marijuana, cocaine or others.
Is there someone I can talk to for help about my drug use?
When it comes to smoking, I:
When it comes to chewing tobacco (snuff, dip, spit tobacco), I:
Does anyone smoke at your home?
Are you exposed to tobacco smoke at work?
During the past two weeks, have you felt down, depressed, or hopeless?
During the past two weeks, have you felt little interest or pleasure in doing things you used to like to do?
Is counseling available to help me with this? Do I need counseling?
My Health Goals
How sure are you that you can manage and control most of your health problems?
My first health goal is:
My second health goal is:
My third health goal is: