USE THIS CHECKLIST TO GUIDE YOUR DISCUSSION AT EACH PRIMARY CARE VISIT.

MEDICATIONS We review your medical records including your medication regimen before each visit, but it’ s always a good idea to quickly discuss them with your provider. Ask:

• Is there a lower-cost option? YES NO

RISK OF FALLS Mark the option that best describes you: m I have had a fall. m I have problems with balancing or walking. m I don’ t have problems with balancing or falling.

BLADDER CONTROL

Mark any that apply to you: m I have problems with bladder control. m I have problems with leaking of urine. m I don’ t have bladder or urine leakage problems.

CARE TEAM List any specialists or other providers you’ re seeing. This will help your Primary Care Provider coordinate your overall care.

MENTAL HEALTH Mark all that currently apply: m I feel calm and peaceful. m I have a lot of energy. m I feel sad or blue. m I am having difficulty sleeping. m Other

Clip and take to your next PCP appointment.

PHYSICAL ACTIVITY Discuss your level of physical activity with your Primary Care Provider. They will work with you to determine if you should start, increase or maintain your current exercise level. Mark any that apply: m I have limitations with my regular daily activities. m I have pain that interferes with my normal work. m I have limitations with my social activities. m I don’ t experience any of the above.

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An important note about test results

We believe that sharing information builds trust and that you should be able to see your results as soon as they are available. By law, test results will be shared with you via MyChart at the same time your provider gets them. Please be patient in allowing your provider to review them and reach out to you with a plan of care. Test results may be difficult to interpret, and may depend upon individual circumstances. We recommend that any time a test is ordered, you ask your provider what the process of getting your test results will be, so you know what to expect.