1. To use this guide, you should: *Talk with the hospital staff about each of the items that are listed in the guide *Take the completed guide home with you. It will help you take care of yourself when you are home. *Share the guide with your family members and others who want to help you. The guide will help them know how to help take care of you. * Bring this guide to all of your doctor appointments so the doctor know what you have been doing to care for yourself since you left the hospital. * This guide helps you to keep track of all the things you need to do.

2. If I have questions or problems, I should call ____________________________________________________ Phone number: ______________________________________ If I have a serious health problem, I should call ____________________________________________________ Phone number: ______________________________________

3. MEDICAL INFORMATION My medical problem is: _______________________________________ ____________________________________________________________ My allergies: ________________________________________________ Medication allergies? Medication_______________Reaction_________________________ Medication_______________Reaction_________________________ What type of exercise is good for me? ___________________________ ____________________________________________________________ What should I eat? ___________________________________________ ____________________________________________________________ What activities or foods should I avoid? _________________________ ____________________________________________________________

4. MEDICATION SCHEDULE MORNING Medicine name (generic and name brand) and dosage Why am I taking this medicine? How much do I take? How do I take this medicine?

5. MEDICATION SCHEDULE AFTERNOON Medicine name (generic and name brand) and dosage Why am I taking this medicine? How much do I take? How do I take this medicine?

6. MEDICATION SCHEDULE EVENING Medicine name (generic and name brand) and dosage Why am I taking this medicine? How much do I take? How do I take this medicine?

7. MEDICATION SCHEDULE BEDTIME Medicine name (generic and name brand) and dosage Why am I taking this medicine? How much do I take? How do I take this medicine?

8. WHAT OTHER MEDICINES CAN I TAKE? Medicine name and amount How much do I take? How do I take this medicine? For a headache or fever For general aches or pains For constipation For diarrhea For insomnia For nausea For

9. NEXT APPOINTMENT Day _______________ Date ____________ Time __________ Doctor __________________________ Specialty _______________ Address __________________________________________________ Phone number ____________________________________________ Reason for appointment ____________________________________ __________________________________________________________ Questions or concerns for this doctor? ________________________ __________________________________________________________

10. NEXT APPOINTMENT Day _______________ Date ____________ Time __________ Doctor __________________________ Specialty _______________ Address __________________________________________________ Phone number ____________________________________________ Reason for appointment ____________________________________ __________________________________________________________ Questions or concerns for this doctor? ________________________ __________________________________________________________

11. NEXT APPOINTMENT Day _______________ Date ____________ Time __________ Doctor __________________________ Specialty _______________ Address __________________________________________________ Phone number ____________________________________________ Reason for appointment ____________________________________ __________________________________________________________ Questions or concerns for this doctor? ________________________ __________________________________________________________

12. NEXT APPOINTMENT Day _______________ Date ____________ Time __________ Doctor __________________________ Specialty _______________ Address __________________________________________________ Phone number ____________________________________________ Reason for appointment ____________________________________ __________________________________________________________ Questions or concerns for this doctor? ________________________ __________________________________________________________

13. NOTES ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

14. NOTES

15. ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________