Skip to main content
Talking with Your Doctor

Discussing Your Concerns with the Doctor: Worksheet

At each visit, your doctor will likely ask about your concerns. It’s a good idea to think about what you’d like to talk about before the actual visit. This form can help you organize your thoughts. Make a copy of the blank form so you will always have a clean copy to use. Then, after you make an appointment, take a minute to write down the name of the doctor and the appointment details (for example, the date, time, and address). Use the form to make a list (in order, from most important to least important) of the concerns you want to discuss.

Doctor:
Appt. Date:
Time:
Address:
Phone:
         

Appointment Details (Most Important to Least Important)

1
2
3
4
5
6
7
8

Notes:

 

 

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.