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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
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
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
Living situation

This content is provided by the National Institute on Aging (NIA), part of the National Institutes of Health. NIA scientists and other experts review this content to ensure that it is accurate, authoritative, and up to date.