Questions for your visit to Dr. Grimshaw

Print this form now to take with you to fill out during your doctor's appointment. In order to make sure you understand your condition and treatment, ask your doctor these questions and write down the answers to review when you are home.

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What is the name of my problem?


What caused the problem?


Will I keep having this problem?

Yes___ No___
How can I stop this problem from occurring again?


Should I take any medications - which ones?

Yes___ No___

What will the medication do?

How should I take the medication?

Morning___ Noon___ Night___

_______times/day _______times/week

Do you have anything written about how this medication works?

Yes___ No___ Available through pharmacist___

Are there any side effects associated with this medication and are there any I should be watching for?

Yes___ No___

When should I call you if these side effects occur?

Immediately___ During office hours____ Next Day_____ Tell you at next appointment_____

If I stop taking the medication, what will happen?

Are there any foods or other drugs that I should not take while on this medication?

Yes___ No___

Are there any other signs of symptoms that I should watch for and call you about?

Yes___ No___

Do I need to limit any activities? How and which ones?

Yes___ No___

Should this restrict my normal daily activities or will I be able to continue to go to work, do physical exercise, etc.?

Yes___ No___

Lab and Diagnostic Tests

Will you need to do any lab or other diagnostic tests?

Yes___ No___

If so, which ones?

What will the tests tell you?

Will someone call me with the results or do I need to call the office?

Yes___ No___ Call the office myself___

How soon will I get the results?

Tomorrow____ This week____ Next week____Exact Date____

Follow Up

Do I need to see a physician specialist?

Yes___ No___

Type of specialist___________________________________________

When is my next return visit?

Exact Date___________________________________________

Do you want me to call you to inform you of my progress?

Yes___ No___

When ___________________________________________

Emergencies: How do I reach you in case of an emergency during daytime and
after office hours?

Daytime ___________________________________________

After Hours ________________________________________