A LITTLE SPACE FOR YOUR THOUGHTS

My appointment notes

Bring your priorities, questions and communication needs together. Complete any sections that help, then print or save your copy.

To type into a worksheet, enable JavaScript in your browser. You can also download the blank PDF and complete it on paper.

Your answers stay in this tab. They are not sent to Elevate or saved on this website. Print or save before leaving or refreshing. On a shared device, clear the sheet when you are finished.

All fields are optional. Use your own words. You do not need to enter identifying or health information to use this tool.

Appointment details

Date, time, place and who you are seeing. Include only what you want on your copy.

Up to 1,800 characters

What I most want to discuss

Start with the things you want the appointment to address.

Up to 1,800 characters

My questions

For example: What are my options? Can you explain that another way?

Up to 1,800 characters

What helps me communicate and take part

You might want an interpreter, extra processing time, written information or a chosen support person.

Up to 1,800 characters

What I want to bring or arrange

Check the appointment instructions, travel and any access arrangements.

Up to 1,800 characters

Afterwards: what was agreed and my next step

Leave this blank for now if you wish. Record who will do what and when.

Up to 1,800 characters

Blank PDF

In the print window, choose a printer or “Save as PDF”. On some phones, saving is available under Share. Only the worksheet is printed.

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