Main concern Forgetfulness or repeating questions Medication, bill, or money mistakes Getting lost, driving, or wayfinding Mood, behavior, sleep, or personality changes Changes after illness, fall, hospital stay, or new medicine
How quickly did it change? Sudden or rapidly worse Over weeks or months Gradual over a year or more Not sure
Safety concern today? No immediate safety concern Some concern at home or outside Urgent safety concern
Current living situation Lives alone Lives with family or regular helper Home with paid care Assisted living, memory care, or facility
Caregiver can attend? Yes By phone or video No Not sure
Medicine list status Current list is ready Partial list or some uncertainty Not ready yet
Recent medical trigger? None known New, stopped, or changed medicine Infection, illness, dehydration, or pain Fall, emergency visit, hospital, or rehab stay Not sure
Need care-plan help? Basic appointment questions Daily support or supervision planning Legal, financial, or decision-helper planning Local services or caregiver support
Driving or wandering concern? No current concern Driving concern Wandering or getting lost concern Both driving and wandering concerns
Appointment type Primary care appointment Medicare yearly Wellness visit Neurology, geriatrics, psychiatry, or other specialist Not scheduled yet
Use this planner to prepare, not to diagnose.
Keep answers general. Do not enter names, addresses, birth dates, diagnoses, Medicare numbers, account numbers, or full medical histories into this worksheet.
If memory or thinking changes are sudden, severe, tied to urgent symptoms, or creating immediate danger, contact emergency services, urgent care, or the care team instead of waiting for a routine visit.
Useful references:
Medicare cognitive assessment care plan services ,
NIA memory problems and aging ,
Alzheimer's Association doctor visits ,
Eldercare Locator .
