Improve Your Medical Care
Action Form

You can print this action form by choosing "Print" from the "File" menu of your web browser.
Printing this action form and taking it to your doctor will help to improve the medical care you receive.
THIS FORM IS INTENDED FOR USE BY YOUR DOCTOR OR NURSE. THEY HAVE BEEN SPECIALLY TRAINED TO USE IT.

NEEDS
	CLINICIAN ASSESSMENTS/ REFERRALS/ACTIONS	SUGGESTED READINGS/EDUCATION
FUNCTION Difficulty with feelings Difficulty with pain SYMPTOMS/BOTHERS Headaches Stomach pain Dizziness/Tiredness Chest pain Menstrual problems Eating/Weight problems CONCERNS OR FAMILY HISTORY Exercise needs Nutrition HABITS PREVENTION No measles/mumps/german measles shot No hepatitis (B) shot OTHER		Exercise and Eating Health Habits and Prevention Feelings Menstruation Pain Tired
		RISK-RELATED CONSIDERATIONS
		Moderate Risk
Italics = Clinician Unaware

Provider:____________________ Date:__________ Signature:____________________
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