Prepared by Jean Miller - A sample letter to provide your physician with a list of up to 5 other symptoms or things you would like them to respond to within a given period of time.
These are items that are not critical, i.e. immediate answer is not required.The top 3 items (above) are those you want answer for immediately. This is good to send into your doctor in advance of an appointment. Keep the list handy on frig, etc. to write down questions as you think about them. Request that a copy of any questions submitted to your doctor, with their response, be placed in your personal medical records in the doctor's office.
Question List To Give To Doctor(s)
Date:____________________________
Doctor:____________________________
Address:___________________________
____________________________
____________________________
Patient:____________________________(fill in ie HD patient)
Address:___________________________
____________________________
____________________________
Tel Number: Area Code ( ) _____________
If applicable, spouse/caregiver contact and telephone number:
_________________________________________
Dear Doctor (fill in)
The following is a list of questions that I would like you to answer.
If you can't answer them all today, (or on my visit ), then I would
appreciate your getting back to me within the(fill in number of days)
with the answers:
Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________
Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________
Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________
Q1___________________________________________________
_____________________________________________________
_____________________________________________________
Doctor's Reply:_________________________________________
_____________________________________________________
_____________________________________________________
These issues are of importance to me Dr. (fill in) and your response will be greatly appreciated.
Respectfully,
(fill in your name/sign
