Memory appointment worksheet
Organise a few observations, the person’s questions and the next steps agreed with the clinic.
Complete the fields below, or print a blank copy and write by hand. Use only the information needed for the conversation. This worksheet is an organisation aid, not a clinical care plan or legal document.
Entries stay on this page and are not sent to the site. Closing or reloading may lose your work. Your browser may separately offer to restore form entries; clear them before leaving a shared device.
Start with their own concern and what they would like help with.
What happened, approximately when, and what help was needed? These are observations, not a diagnosis.
Note where the current medicine list and relevant appointment information are kept. Do not enter identity numbers here.
What is uncertain? What should happen next? Who should we contact?
Record the action, responsible person, date and contact route agreed at the appointment.
AlzheimersFoundation.ca · Independent educational resource · Privacy information