Main communication barrier Hearing conversations, phone calls, or instructions Reading papers, labels, screens, or signs Both hearing and vision Not sure what is causing the difficulty
Where it causes the most trouble Medical appointments or pharmacy visits Daily routines at home Phone calls, video visits, or patient portals Transportation, errands, senior programs, or housing
Change pattern Gradual change Recent noticeable change Sudden or rapidly worse After illness, fall, hospital stay, or medicine change
Current device or aid status No hearing aid, glasses, magnifier, or device in regular use Has aids or glasses, but they are hard to use Needs repair, cleaning, fitting, battery, or prescription check Devices are working and used most days
Appointment support No support plan yet Caregiver or trusted helper can attend Need interpreter, captions, large print, or quiet room Need written plain-language summary after visits
Home setup status Lighting, contrast, labels, and sound setup not reviewed Some fixes started Missed medicines, falls, cooking, or missed calls are a concern Home setup reviewed recently
Coverage or cost question Not sure what Medicare or the plan covers Hearing aids, fitting exam, batteries, or audiology Eye exams, glasses, low-vision devices, or treatment Coverage path is mostly understood
Caregiver role Older adult planning for self Nearby family or friend helps Long-distance family helps Paid caregiver, home health, or facility staff involved
Next professional to contact Primary care clinician Eye doctor, audiologist, hearing professional, or ENT Medicare, plan, Medicaid, VA, or SHIP Area Agency on Aging, ADRC, or community program
Use broad planning answers only.
Do not enter names, diagnoses, Medicare numbers, Social Security numbers, account numbers, portal passwords, device serial numbers, or private medical details. Keep personal notes in a secure care folder.
This planner is educational and organizational only. It is not medical, vision, audiology, legal, insurance, benefits, financial, tax, accessibility-rights, or emergency advice. Sudden vision loss, sudden hearing loss, severe dizziness, stroke symptoms, injury, or immediate danger should be handled urgently with qualified care or emergency services.
Official references:
NIA communication guidance for older patients ,
NIA aging and your eyes ,
NIDCD assistive devices ,
Medicare services not covered by Original Medicare .
