Worksheet 3
Changes to Discuss
Tell your doctor about any changes in your life since your last appointment. The list below can help you think of what to mention. Of course, all the things on this list won’ t apply at every visit! Tear out this form and make a copy of the blank list so you will always have a clean copy to use. Or you can download additional copies of the form at www. nia. nih. gov / health / twyd-worksheets. Then, take a minute to think about each of these possible topics. Jot down when you first noticed each change. Use the last column to note any additional information that may be helpful for the doctor to know.
Topic Date Notes
Your Physical Health
Recent hospitalizations or emergencies
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Bone / Joint pain or stiffness
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Bowel / Bladder problems
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Chest pain / Shortness of breath
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Headaches / Feeling dizzy or lightheaded
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Vision / Hearing changes
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Skin changes
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Your Medications, Mental Health, and Lifestyle
Alcohol use
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Weight changes
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Talking With Your Doctor 43