Heath and Aging

Talking With Your Doctor: A Guide for Older People

For Your Convenience: Worksheets

WORKSHEET 1

Concerns

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:

 

 

WORKSHEET 2

Changes to Discuss

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
   

 

WORKSHEET 3

Medications

You may be taking many different medicines as well as numerous vitamins and over-the-counter drugs. It can be confusing to keep track of everything! This form can help. Because your medication regimen may change over time, make a copy of the blank form so you will always have a clean copy to use. Try to bring a completed and updated copy of this form to every doctor appointment.

Name of Drug What It's For Date Started Doctor Color/Shape Dose and Instructions
           
           
           
           
           
           
           
           
           
           
           
           

Any Suggestions? Closing Thoughts

If you have suggestions to add to future editions of this publication or other ideas for making it more helpful, please contact National Institute on Aging, Office of Communications and Public Liaison, Building 31, Room 5C27, 31 Center Drive MSC 2292, Bethesda, MD 20892-2292; niaic@nia.nih.gov.

Publication Date: April 2010
Page Last Updated: April 28, 2016