Complete, print, and bring to any visit you have with a health professional.

Previsit questionnaire

Basic info

Events - things that have happened to you since your last visit (existing patient) or in the past year (new patient)

Issues - how you felt most days in the past week

Wishes - what are ONE or TWO main things that would make your life better?

Scores

Suggestions

Events

Car accident - check out Older Drivers - AgePage and Older Drivers - NIHSeniorHealth for information that may help.
Death of a spouse - check out Mourning the Death of a Spouse for information that may help.

Issues

Anxiety/stress - check out Anxiety Disorders, Elder Abuse, and Crime and Older People for information that may help.
Caring for someone else - check out 6 Signs of Caregiver Burnout - AARP for information that may help.
Chest pain or pressure - check out Heart Health for information that may help.
Constipation - check out Concerned About Constipation? for information that may help.
Difficulty walking - check out Gait and Balance Disorders in Older Adults for information that may help.
Dizziness - check out Dizziness and Vertigo for information that may help.
Fear of death - check out 6 Positive Ways To Overcome Your Fear Of Death - Huffington Post for information that may help.
Fear of disability or being a burden - check out Moving Past Your Fear of Being a Burden for information that may help.
Fear of falling - check out Falls and Older Adults and Falls and Fractures for information that may help.
Indigestion/nausea - check out Indigestion (Dyspepsia) for information that may help.
Loneliness/boredom - check out Easing Old People's Loneliness Can Help Keep Them Healthy - NPR for information that may help.
Low energy - check out Fatigue: More Than Being Tired for information that may help.
Low mood - check out Depression for information that may help.
Managing your health problems - check out Health Screenings and Immunizations for information that may help.
Managing your medications - check out Medicines: Use Them Safely, Drugs in the Body, and Prescription and Illicit Drug Abuse for information that may help.
Memory loss - check out Forgetfulness: Knowing When to Ask for Help and Alzheimer's Disease for information that may help.
New non-prescription medication or supplement - check out Dietary Supplements for information that may help.
Overall health/quality of life - check out Quality of life - Wikipedia and 10 Things You Can Do Today to Improve Your Life - Psychcentral for information that may help.
Pain - check out Pain: You Can Get Help for information that may help.
Poor appetite - check out Healthy Eating After 50, Eating Well As You Get Older, and Taking Care of Your Teeth and Mouth for information that may help.
Poor sleep - check out A Good Night's Sleep and Sleep and Aging for information that may help.
Sex life - check out Sexuality in Later Life for information that may help.
Shortness of breath - check out Understanding Lung Problems—Make Each Breath Healthy for information that may help.
Unintentional weight loss - check out Unintentional Weight Loss in Older Adults for information that may help determine what's going on.
Unsteadiness - check out Balance Problems for information that may help.
Urine leakage/incontinence - check out Urinary Incontinence - AgePage and Urinary Incontinence - NIHSeniorHealth for information that may help.
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