Skip to main content
Talking with Your Doctor

Discussing Changes in Your Health: Worksheet

Your doctor may want to know about any changes in your life since your last appointment. It is useful to consider what you should say before you see the doctor. The list below can help. Of course, all the things on this list won’t apply at every visit! Make a copy of the blank list so you will always have a clean copy to use. Then, take a minute to think about each of these possible topics. You may want to jot down when you first noticed each change. You can use the last column to note any additional information that may be helpful for the doctor to know.

Your Health
Topic Date Notes
Bone/joint pain or stiffness
   
Bowel problems
   
Chest pain
   
Feeling dizzy or lightheaded
   
Headaches
   
Hearing changes
   
Losing urine or feeling wet
   
Recent hospitalizations or emergencies
   
Shortness of breath
   
Skin changes
   
Vision changes
   

 

Your Diet, Medication, and Lifestyle
Topic Date Notes
Alcohol use
   
Appetite changes
   
Diet/nutrition
   
Medicines
   
Tobacco use
   
Weight changes
   

 

Your Thoughts and Feelings
Topic Date Notes
Feeling lonely or isolated
   
Feeling sad, down, or blue
   
Intimacy or sexual activity
   
Problems with memory or thinking
   
Problems with sleep or changes in sleep patterns
   

 

Everyday Living
Topic Date Notes
Accidents, injuries, or falls
   
Advance directives
   
Daily activities
   
Driving/transportation/mobility
   
Exercise
   
Living situation