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Top 3 Things To Discuss With Doctor
Prepared by Jean Miller-A list of the top 3 things or symptoms of critical importance to you that you want to discuss with your doctor on your next appointment or have them respond, in writing, as soon as possible.
It is a good idea to keep a notebook handy where you can write down unusual or changed symptoms that you would like to discuss with your doctor. Ask your family members, too, if they have noticed anything which they feel needs to be brought to your doctor's attention.
Prior to the next appointment, consider the top 3 items which are causing you the most concern and present those to the doctor requesting answer DURING that visit. Make a separate list (see next form) of questions to leave with the doctor, requesting they get back with you on those questions.
It is recommended you fax both the "Top 3" and the "Question List To Give To Doctor(s)
lists to the doctor in 1 to 2 days in advance of your appointment, then bring spare copies to discuss and leave with them during your visit.
INFORMATION TO BE SENT TO YOUR PHYSICIAN
Date:_____________ Date of Appointment:__________
Patient:_______________________ Patient Number:_____________
Address:______________________
_______________________
_______________________
Tel Number: ( ) ________________
If applicable, spouse or caregiver/emergency contact:
________________________________/Telephone____________________
Dear Doctor (fill in name)
The following is a list of problems or symptoms that I have been experiencing.
These have been giving me the most difficulty and are impacting my quality
of life. Therefore, during the course of my next appointment (or via return mail if
you do not have an upcoming appointment), I would like your comments and/or
recommendation on how to address these items:
1______________________________________________________________
_______________________________________________________________
Doctor's Response ________________________________________________
_______________________________________________________________
_______________________________________________________________
2_______________________________________________________________
________________________________________________________________
Doctor's Response:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3________________________________________________________________
_________________________________________________________________
Doctor's Response:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Respectfully,
(fill in and sign your name)
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