Your Medical History Checklist

What other health problems do you have? Other diagnosis?

What medications, drugs or treatments are you now taking?

What treatment options have you been given? Curative, major interventions, or comfort care and hospice?

Do you live in an urban or rural area? May affect care options.

• Unintentional weight loss
• Decreased grip strength
• Increased fatigue/low energy level
• Slow walking
• Low level of physical activity

• Have you lost any parents or children?
• Have you lost a wife or husband?
• Have you lost some good friends?
• Have you lost pets?
• When did these losses occur?
• How did you deal with these losses?

Have you been or are you being treated for depression?

Have you been or are you being treated for anxiety?

Have you been treated for other psychological conditions?

• How physically active are you?
• How mentally active are you?
• What do you like to do?
• How stable is your weight?