Printable Version of Little Giri™

Little Giri™ ?

• Down load the form , we call Little Giri™ and type in the information. You can then print it and take it with you when you go to see your doctor.
• This is a win-win situation for you and your doctor. By providing all this information on a piece of paper, you are saving your doctor’s time. This will help your doctor spend more time working with you on your concerns.
• If you have older loved ones, sit down with them and help them fill the form, so that they do not forget the key information during their clinic visits
• You are welcome to let your physicians know that this form is available so that they can tell their other patients about this important vehicle of communication
• If you have a loved one in a nursing home or a care center, request the nurses there to complete this form before your loved one is taken to a doctor’s appointment.  

Terms of use

• Make sure you do not complete this form while on drchander.com, or e-mail it to us. The information that you are providing is privileged information and should only be shared with the persons that you choose.
• This form has been created to help you get the best out of your visit with your doctor. You are most welcome to download it for personal use. The commercial use of this form without permission from drchander.com is prohibited.

© Keshav Chander

Fill the form below. The boxes below will expand to accommodate the information you type. For explanation for each numbered item below, go to the corresponding number on the next page.

© Keshav Chander

1.

• Here you describe why you are in the doctor’s office. This should be the main reason that brought you to the doctor’s office that particular day. You should add other symptoms under review of systems
• If you are seeing a specialist, just saying that your primary doctor wanted you to see her is not enough. If your doctor refers you to another doctor, ask the reason for referral. If it is because of an abnormal test, get a copy of the test and hands carry it when you go to the specialist appointment. This is the best way to assure that you have all the important information when you go for the appointment

2. This is your medical history as you know it. Write all the medical conditions you have had. If you were told ten years back that you had high blood pressure, say so; even if you have not taken any medicine for that all this time

3. Write down all the surgical procedures you have had.

4.

• Write down all the medicine you are taking. Make sure you spell the names right. Also write the dose and the number of times you take that medicine. Write this in an easily understandable form like: ibuprofen 600 mgm. Once/twice/three times a day.
• If you do not understand some medicine right, take the prescription bottle with you. If you take your medicine at a certain time, write that. If you take the medicine at a certain time for a reason, write that too. For example, taking a blood pressure medicine at a certain time may have taken away your dizziness. Telling this to your doctor will assure that your doctor does not have to reinvent the wheel, so to speak.
• When writing medicines, don’t forget over the counter medicines and herbs you are taking.
• Most of the physicians do not have any knowledge of most of the herbs. Moreover, many natural products are a combination of tens of different products. Read up on all the information on the natural product and share that information with your doctor. Some pharmacies now have computer programs that can give interactions between commonly used herbs and conventional medicines. Ask your pharmacist about that. Make sure you share the information that you get with your doctor. Short of all that, you are pretty much taking natural products at your own risk.

5. Write the names of all the medicines that you have been allergic to. Also write down the symptoms of that allergic reaction. This is important because ill effects that you had from a certain medicine may not technically be classifiable as an allergic reaction. For example, the stomach upset that you had from aspirin is not an allergic reaction. And, in the absence of a serious reaction, your doctor may see aspirin as a life saver if just had a heart attack.

6. Write down (if known) the significant medical problems that your siblings or parents had; at what age they had those and (for those deceased), the cause of death. If you are not sure of a certain medical condition that your relative might have had, say so. For example, do not presume a diagnosis of heart attack if one of your relatives died at a young age without a prolonged illness.

7. Do you smoke or drink alcohol, and how much? If you quit, when did you do that? Do you or have you ever used drugs? What do you do, and what jobs did you hold in the past. This may help your physician decide if any of your problems are occupation related. If you see any other social issues that you see as important, write those down. For example, taking care of your elderly father with severe Alzheimer’s may explain a squeezing sensation in your chest, and palpitations.

8.

• This is a place where you report all the symptoms that you have been feeling, however seemingly frivolous. Writing all this down can save you a considerable amount of time.
• The physicians are used to doing this part of the history system wise. For example, cardiac, kidneys etc. for your convenience, you can write all the symptoms going from head to toe

9.

• Here, you write what you want to achieve out of the clinic visit. Most of the time, the reason for coming to the doctor’s office (written in column 1) is one question that needs to be addressed. For example, if diarrhea brought you to the office, we need to address that issue. But do not take any thing for granted. Write down “what is causing my diarrhea” here also.
• Also write any other concerns that you have. It is important that you fill in this portion. This will contribute a lot toward your satisfaction with your visit with your doctor. This will help your doctor focus on your concerns. Remember, your doctor’s and your concerns may not necessarily coincide. For example, you have a real itchy rash on your left forearm but you also had an episode of squeezing in the chest while mowing the lawn the other day. The squeezing in the chest may get your doctor concerned and really excited while it is the rash that has been keeping you awake for last so many nights.

10. Here you write all the updates that happen with time. For example, did your visit to another doctor lead to some new diagnosis or new medicines?

© Keshav Chander

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