Health Worksheets
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Problems and Complaints
My Complaint
If you have a complaint, use this worksheet to keep track of details, such as dates, the people you talked to, decisions made, and next steps.
My Emergency Contact List
Use this form to write down emergency phone numbers, including the numbers for your family’s health plan and doctors.
Health Plan Basics
My HMO Costs
Fill out this worksheet to estimate your out-of-pocket expenses if you are in an HMO.
Compare HMO Costs
Use this form to compare costs for each HMO you are considering.
My PPO Costs
Fill out this worksheet to estimate your out-of-pocket expenses if you are in a PPO.
Compare PPO Costs
Use this form to compare costs for each PPO you are considering.
Learning New Habits
Use this form to list things you can do to help follow your treatment plan.
Ask About Benefits
Trying to decide if a health plan is right for you? Use this form to evaluate the benefits of each plan you are considering.
Getting Better Care
Choose a Doctor
Do you need to find a new doctor? Use this worksheet to help find a doctor who meets your needs.
Make the Most of Doctor Visits
Use this worksheet to help prepare for your doctor visits.
My Medicines
Use this worksheet to list all the medications that you are taking. Share this with your doctor and keep a copy in your wallet.
My Health History
Use this form to keep a record of your health care, past conditions, and family health history. Bring it with you when you go to a new doctor.
Prepare for a Hospital Stay
Are you unsure of what to expect when you go to the hospital? This worksheet will help you prepare.
Communication Assistance If You Have a Disability
Share this worksheet with your doctor's office so they know how you want to communicate.
Physical Access If You Have a Disability
Share this worksheet with your doctor's office so they know what physical accommodations you need during your visit.
Prenatal Care
This worksheet can help you keep track of care you need and things to ask at every stage of your pregnancy.
Care for Children
Use this form to make sure your child gets the health care he or she needs.
Care for Women 18-34
This form helps you keep track of screening tests, preventive care, and common health conditions for women that you may need to discuss with your doctor. Use it to help you prepare for your next visit.
Care for Women 35-50
This form helps you keep track of screening tests, preventive care, and common health conditions for women that you may need to discuss with your doctor. Use it to help you prepare for your next visit.
Care for Men 18-34
This form helps you keep track of screening tests, preventive care, and common health conditions for men that you may need to discuss with your doctor. Use it to help you prepare for your next visit.
Care for Men 35-50
This form helps you keep track of screening tests, preventive care, and common health conditions for women that you may need to discuss with your doctor. Use it to help you prepare for your next visit.
Care for Adults 50+
This form helps you keep track of screening tests, preventive care, and common health conditions for older adults. Use it to help you discuss these topics with your doctor at your next visit.
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