Clinician Action Form

Improve Your Medical Care
Action Form

Name:________________________________		Date:__________	Age:__________	Gender:__________
A S S E T S	FUNCTION	HABITS Does not smoke Does not drink	KNOWLEDGE Has medication list	PREVENTION Had flu and pneumovax shots
NEEDS		CLINICIAN ASSESSMENTS/ REFERRALS/ACTIONS		SUGGESTED READINGS/EDUCATION
FUNCTION Poor overall health Extremely bothered by emotions; unable to do housework; get out SYMPTOMS/BOTHERS trouble thinking; sleep; foot problems; CONCERNS OR FAMILY HISTORY DEVICES USED Cane; glasses HABITS PREVENTION No written advance care plan; tetanus shot; home hazard info; 3 or more medications; lacks essential money; $60 or more/month for meds OTHER italic - Clinician Unaware		Clinician writes notes here		Advance Directive; Assistive Devices, Emotional Care; Foot Care; A Good Night's Sleep; Daily Activities; Medications; Preventing Falls
				RISK-RELATED CONSIDERATIONS
				High Risk Practice/Clinician has standard suggestions/ phone numbers, etc. written in here auto- matically for risk level.
Provider:____________________________		Date:__________	Signature:_____________________________