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form and fill in the information for blood, urine, X-ray, or any other test
your doctor recommends. You may need to make copies if more than one test is
What is the name of the test?
Why do I need this test?
What might happen if the test is delayed or not
How accurate is the test? Are there other tests that are
How much does the test cost?
Is there a less expensive test that might give the same
What should be done to prepare for the
Where will the test be done?
How long does this test take?
How will I feel during the test? Is it
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
Will other tests be needed?
ByHealthwise StaffPrimary Medical ReviewerAdam Husney, MD - Family MedicineSpecialist Medical ReviewerMartin J. Gabica, MD - Family Medicine
Current as ofFebruary 19, 2016
Current as of:
February 19, 2016
Adam Husney, MD - Family Medicine & Martin J. Gabica, MD - Family Medicine
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