💡 How to use this sheet: Fill the sections below before your appointment.
Bring the completed sheet with you. Use the Doctor's Responses section during the visit.
Leave with a complete record — no reconstructing from memory.
VISIT INFORMATION
Patient name
Date of visit
Doctor / clinic name
Next appointment
CURRENT MEDICATIONS (bring the actual bottles if possible)
| Medication name | Dose | Timing | Purpose | Any concerns / side effects? |
|---|---|---|---|---|
OBSERVATIONS SINCE LAST VISIT
| What I observed | How often / How severe | Any pattern or trigger? |
|---|---|---|
| Memory / confusion changes | ||
| Behaviour changes (agitation, wandering, paranoia) | ||
| Mood / personality changes | ||
| Sleep problems | ||
| Falls or near-misses | ||
| Appetite / weight changes | ||
| Pain indicators |
MY TOP 3 CONCERNS FOR THIS VISIT
1
2
3
QUESTIONS TO ASK (circle what applies to today's visit)
Has the stage or progression changed?
Are all current medications still appropriate?
Are there medication interactions I should know about?
Should we reassess driving fitness?
Is there a referral to OT or geriatrician needed?
Should we start the long-term care waitlist now?
What symptoms should prompt me to call before next appointment?
Are there non-medication approaches to try for current behaviours?
Is there a social worker or care coordinator I should speak with?
What does the next 6 months likely look like?
DOCTOR'S RESPONSES & NEXT STEPS (fill during the visit)
| Key information / advice from doctor today | Action / Next step | Who is responsible | By when |
|---|---|---|---|
BC Resources:
Fraser Health Access Line 1-877-935-5669 ·
Alzheimer Society BC First Link 1-800-936-6033 ·
BRELLA Community Services brellasociety.ca ·
Specialist second opinion within days: giniehealth.com ·
Free care navigation call: gurjotnarwal.com/how-i-can-help