Patient homework

by Christina on March 14, 2013

I finally made myself a doctor’s appointment and before my appointment I had to fill out a questionnaire.

Well! What a great idea Put the patient to work. Have them do some pre-contemplation and goal setting before the visit. Help them feel invested in your time together.

The questions I had to answer included the following:

  • How would you rate your current physical health? List specific health problems you are currently experiencing.
  • How would you rate your current sleeping habits? List any specific sleep problems you are currently experiencing.
  • How many times were week do you exercise? What types of exercise do you participate in?
  • Please list any difficulties you experience with your appetite or eating patterns?
  • Are you currently experiencing overwhelming sadness or grief?
  • Are you currently experiencing anxiety?
  • Are you currently experiencing any chronic pain?
  • Do you drink alcohol? Drug use? Tobacco?
  • Are you currently in a romantic relationship? On a scale of 1-10, how would you rate your relationship?
  • What significant life changes or stressful events have you experienced recently?
  • List health problems in your family.
  • What is your current employment situation?
  • Do you enjoy your work? Is there anything stressful about your current work?
  • Do you consider yourself spiritual or religious? Describe your faith or belief.
  • What do you consider to be some of your strengths?
  • What do you consider to be some of your weaknesses?
  • What would you like to accomplish out of your time with your physician?
Anything missing? I think I’ll be making up a form to give out to my patients!

{ 3 comments… read them below or add one }

Chris March 15, 2013 at 12:57 am

I really like this idea! So smart!


Kim March 23, 2013 at 5:54 pm

Before my chiropractor appt, his questionairre included, “what the biggest source of stress in your life?”
I though that was a good one!


Emily June 22, 2014 at 10:01 am

First year med student, we practiced the art of thorough history taking quite frequently. How about instead of rating a romantic relationship (what even are you ranking about it, seems too ambiguous and up to pt interpretation) you ask if they feel safe in their relationship. That gets more at a physical and mental concern. Just my 2 cents!


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