Concerns To Discuss

This form can help you organize your concerns, symptoms, or other health matters that you’d like to discuss with your doctor. 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 (the date, time, address). Use the form to make a list of the concerns you want to discuss, starting from most important to least important.

Doctor: __________________________________________________________________________________

Appointment Date: ________________________________________________________________________

Time: __________________________________________________________________________________

Address: ________________________________________________________________________________

Phone: ___________________________________________________________________________________

Appointment Details (Most Important To Least Important)

NOTES

For more resources on health and aging, visit: www.NIHSeniorHealth.gov

Last reviewed: September 2014