Printable patient document
Consultation Checklist
Printable consultation checklist for symptoms, medicines, allergies, reports and questions, authored and reviewed by Dr. Himanshu Yadav.
Dr. Himanshu Yadav
M.S., M.Ch. (Surgical Gastroenterology), SGPGIMS Lucknow
Director, Dr Himanshu's Clinic, Agra
Director, Dr Himanshu's Clinic, Agra
Consultation Checklist
Complete what you can before the appointment and bring this sheet with your existing medical records.
Patient and appointment details
Name
Age
Appointment date
Phone
Referring doctor
Preferred language
My main concern
Symptoms began
Main symptom
Records to bring
- Current medicine and supplement list
- Medicine and other allergy list
- Blood-test reports
- Ultrasound, CT or MRI report and images
- Endoscopy or colonoscopy report
- Biopsy or pathology report
- Previous operation/discharge records
- Identification and appointment papers
Medicines, vitamins and supplements
| Name | Dose | When taken | Reason |
|---|---|---|---|
Allergies
Allergy reaction
Questions I want to discuss
- What may be causing my symptoms?
- Do I need another test?
- What are my treatment options?
- What are the benefits and important risks?
- What happens without treatment now?
- Which symptoms need urgent help?
Agreed next steps
Reminder: Do not arrange tests or stop medicines solely because they appear on this checklist. Use it to support a discussion with the treating clinician.