Print this 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 recommended.
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?
Questions to ask about the test
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 will the results show?
Will the results change the treatment? No ___ Yes ___ 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 receive a phone call from my doctor:
Date for a follow-up appointment:
After the test, what will be the next step?
Will other tests be needed?
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