Health Literacy Universal Precautions Toolkit, 2nd Edition

Adult Return Visit Update Form

[Microsoft Word file Microsoft Word version - 22.27 KB]

Patient Name                                                                          Date                        

 

1. What would you like to talk to the doctor about today?

  1.                                                                                                                    

  2.                                                                                                                     

  3.                                                                                                                    

2. How would you describe your health since your last visit?

___ Excellent      ___ Very Good      ___ Good      ___ Fair      ___ Poor

3. Have you been in the hospital or been to the Emergency Room since your last visit?

___ Yes  ___  No.

4. Have you seen any other doctors since your last visit?

___ Yes  ___  No.

5. Have your medicines changed since your last visit?

___ Yes  ___  No.

6. Have you been exercising?

___ Yes  ___  No.

7. Have you been hit, pushed, shoved, kicked, or threatened by someone important to you?

___ Yes  ___  No.

8. During the past 2 weeks, have you often been bothered by having little interest or pleasure in doing things?

___ Yes  ___  No.

9. During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless?

___ Yes  ___  No.

Return to Contents

Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Adult Return Visit Update Form. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool11c.html