On this page
Use this sheet to prepare a conversation about a practical change at work. Start with the task that has become difficult, the change you want to discuss and what you prefer to keep private. You can use it while seeking help with perimenopause or menopause concerns, without asking your manager to explain your symptoms.
Print it or copy the fields into a document you control. Yellow at spotyellow.in does not collect the answers. This is a conversation template, not medical advice, a statement of employment rights or a promise that a request will be accepted.
Name the work situation
The task or part of my day I want to discuss: ____________________
A recent example, with a date if useful: ____________________
What I want to be able to do: ____________________
Describe an observable situation. A hypothetical example is: “On days with back-to-back client calls, I cannot find a private slot for a booked appointment. I would like to discuss protecting that slot and arranging cover.” Replace this with your own situation.
Keep any explanation of symptoms separate from assumptions about their cause. Your appointment observation notes belong with your practitioner unless you choose to share part of them. A work discussion does not replace medical assessment.
Choose one request to discuss first
The change I want to ask about: ____________________
When or where it would apply: ____________________
A practical constraint we need to consider: ____________________
Another option I would be willing to discuss: ____________________
Possible discussion topics include a private place for an appointment call, a written summary after a meeting, or an agreed break between scheduled activities. These are examples of requests, not proven treatments or guaranteed entitlements.
If your role involves safety procedures, ask how a proposed change would fit them. Do not use this worksheet to bypass a workplace safety rule or decide that you are fit for a particular task.
Decide what you want to share
Person I plan to contact: ____________________
Their role and contact route: ____________________
What I am comfortable explaining: ____________________
What I want to keep out of this conversation: ____________________
Question about who can see or retain the information: ____________________
You might begin: “I would like a private conversation about a change that could help me manage this part of my working day. Can you explain the process and who would be involved?”
Ask your organisation which policy or process applies and whether it asks for supporting information. This sheet does not say what an employer can require. If the answer raises a legal concern, seek advice appropriate to your circumstances rather than relying on a template.
Record the reply without assuming agreement
| What I asked for | Reply or question received | Next person or action | Date |
|---|---|---|---|
| ____________________ | ____________________ | ____________________ | ____________________ |
| ____________________ | ____________________ | ____________________ | ____________________ |
Agreed change, if any: ____________________
Still being considered: ____________________
Not agreed, or an alternative proposed: ____________________
Who will confirm the next step: ____________________
A suggestion during a conversation is not the same as an agreed arrangement. Ask for a short written summary if you want one, and correct anything that does not reflect the discussion.
Agree how to review the arrangement
Start date, if agreed: ____________________
Date to discuss how it is working: ____________________
Work task we will use to judge whether the arrangement is practical: ____________________
Contact if the arrangement cannot be used: ____________________
Keep the review about the agreed work arrangement. You do not need to turn this sheet into a daily symptom report. If the original request did not help with the task, note what happened and what you want to discuss next.
Keep your care and work records separate
For personal health questions, use the appointment preparation guide with your practitioner. If someone accompanies you, the sharing checklist helps you decide what they can contribute.
You can also explore Yellow for Hormones for separate programme information. It is optional and is not an employer service, legal adviser or substitute for medical care. You can use this worksheet without joining a programme.
My next action: ____________________ By: ____________________
This resource provides general information and does not diagnose a condition or replace advice from a qualified practitioner.