Health Library
We have a vast digital library of medical information, including wellness and psychiatry topics as well as general medical topics. For more information or to schedule an appointment, don’t hesitate to call us.
Our Health Library information does not replace the advice of a doctor. Please be advised that this information is made available to assist our patients to learn more about their health. Our providers may not see and/or treat all topics found herein. Complete this form if you are seeing this health professional for the first time. Although you may have to complete a similar form when you arrive at the office, completing this form will help you organize your thoughts and provide more complete information. Complete Section 2 at the end of your appointment if you have a health problem that needs treatment. Why did I make this appointment? Am I having any symptoms? Describe them. If pain is one of my symptoms, include where it is, how it feels, and how severe it is. Has there been a recent change in my normal routine (for example, sleeping, eating, recent death of a loved one, divorce)? Am I pregnant? Yes____ No____ When was my last menstrual period? _________ At what age did my menstrual cycles begin? _________ My cycles are: Regular____ Irregular ____ When was my last mammogram? _________ If the results were abnormal, explain: When was my last Pap smear? _________ If the results were abnormal, explain: When was I last screened for colon cancer (if I am older than 50)? _________ If the results were abnormal, explain: When was my last prostate examination (if I am older than 50 and younger than 75)? _________ If the results were abnormal, explain: When was I last screened for colon cancer (if I am over age 50)? _________ If the results were abnormal, explain: Health problems. List your current health problems, such as poor eyesight or diabetes, and the name of the health professional you see for each problem. Hospitalizations. Provide information for each time you have been in the hospital. Include any surgeries you have had on an outpatient basis. Date of when I was there _______________________________ Date of when I was there _______________________________ Date of when I was there _______________________________ Allergies. Fill in the following information if you have allergies to medicines or other substances. Medicine or other substance _______________________________. My reaction: Medicine or other substance _______________________________. My reaction: Medicine or other substance _______________________________. My reaction: Family history. List family members (parents, brothers, sisters, grandparents) who have or had the following major conditions. Health condition Relative (parent, brother, sister, grandparent) Age, if living Age at death Comments Tobacco and alcohol use Product (cigarettes, cigars, pipe, vape, or chewing tobacco) How much am I using now, or how much did I use before I quit?(for example, 1 pack of cigarettes a day or 1 cigar about once a week) How long has it been since I quit? Physical exercise What type of exercise do I do? (for example, walking, jogging, stretching) How frequently do I exercise? (for example, 3 times a week) ___________________ How long do I exercise each time? (for example, 10 minutes, 30 minutes) ___________________ Personal preferences. Do I have any cultural, religious, or personal beliefs that may affect my treatment options? Describe them briefly: Stop here. By the end of your appointment, make sure you have answers to the questions in Section 2 if you need treatment for a health problem as the result of this visit. What is the diagnosis? What does it mean in plain English? What might happen next? Do I need a medicine?Yes ___ No ___ If yes, fill in the following information. Do I need surgery or another treatment?Yes ___ No ___ If yes, fill in the following information. What are the risks and benefits of medicine, surgery, or other treatment? Fill in the following information about the treatment your health professional recommends for this condition. Do I need a medical test or X-ray?Yes ___ No ___ If yes, fill in the following information. What home treatment can I do? Ask the following questions about what you can do to help treat your condition. What do I need to change? How? What home treatment do I need to add? (for example, using a humidifier) Do I have concerns about being able to carry out my part of the treatment?Yes ___ No ___ If yes, discuss them with your health professional now. When should I contact my health professional? Fill in the appropriate box below with the date and time, if needed. Check here if no contact is needed ___________ Call for test results or to report how I am doing: Return for an appointment: Reminder Bring to your appointment all your medicines or a list of all the medicines you are taking. Current as of: July 1, 2025 Author: Ignite Healthwise, LLC Staff Current as of: July 1, 2025 Author: Ignite Healthwise, LLC Staff Clinical Review Board This information does not replace the advice of a doctor. Ignite Healthwise, LLC disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use and Privacy Policy. Learn how we develop our content. To learn more about Ignite Healthwise, LLC, visit webmdignite.com. © 2024-2025 Ignite Healthwise, LLC.Topic Contents
First Appointment
Section 1: Current health and health history
Questions for women
Questions for men
Immunization history
Health history
Heart problems Kidney disease Lung disease Depression or other major mental health condition Diabetes Breast cancer Colon cancer Other cancer or inherited disease Section 2: Treatment for this health problem and next steps
Related Information
Credits
Clinical Review Board
All Ignite Healthwise, LLC education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.
All Ignite Healthwise, LLC education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.
