Use this form for any tests your doctor recommends, such as blood tests, urine tests, or X-rays.
What is the name of the test?
Why do I need this test?
What might happen if the test is delayed or not done?
How accurate is the test? Are there other tests that are more accurate?
How much does the test cost?
Is there a less expensive test that might give the same information?
What should be done to prepare for the test?
Where will the test be done?
How long does this test take?
How will I feel during the test? Is it painful?
Will I need to arrange for someone to take me home after the test?
What are the risks?
What can the results show?
Will the results change the treatment? Yes ___ No ___ If yes, explain:
What can affect the results (for example, food, exercise, medicine, alcohol, or smoking)?
When will the results be available?
Date I will be notified about my test results:
Date for a follow-up appointment:
After the test, what will be the next step?
Will other tests be needed?
Current as of:
June 27, 2022
Author: Healthwise StaffMedical Review: Adam Husney MD - Family MedicineMartin J. Gabica MD - Family Medicine
Current as of: June 27, 2022
Author: Healthwise Staff
Medical Review:Adam Husney MD - Family Medicine & Martin J. Gabica MD - Family Medicine
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