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PATIENT EDUCATION PACKET
ACKNOWLEDGEMENT FORM
The following Patient Education Packet was reviewed and given to for this patient and/or caregiver:
 Chest Pain Packet (Myocardial Infarction, Coronary Artery Disease, Angina, Chest Pain)
 Micromedex Print Outs for diagnosis
 Community Education Resources
 Living Heart Smart handout
 Cardiologist Groups Listings
 Cardiac Rehabilitation tear off sheet by Pritchett & Hull
 Learning About Coronary Artery Disease tear off sheet by Pritchett & Hull
 Your Blood Pressure tear off sheet by Pritchett & Hull
 Cholesterol & Your Health tear off sheet by Pritchett & Hull
 Risk Factors of Coronary Artery Disease tear off sheet by Pritchett & Hull
 Exercise and Coronary Artery Disease tear off sheet by Pritchett & Hull
 Controlling Blood Pressure with Diet (DASH Food Plan) tear off sheet by Pritchett & Hull
 Learning About Stress tear off sheet by Pritchett & Hull
 Diabetes Packet
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Flyer on Diabetes Self-Management Education with RMC Diabetes Programs, support group &
telephone number to register for classes
Diabetes Education A Fresh Approach to Healthcare booklet by RMC
Good Measure Meals booklet
Card with American Diabetes Association (ADA) contact telephone number & website
information
American Diabetes Association registration card
Trial Membership card of 1 month free subscription for the Diabetes Forecast Magazine
World’s Best Books for People with Diabetes (ADA catalog to order books)
Could You Have Diabetic Neuropathy and Not Know It? Taking Care of Your Feet flyer by
ADA
Welcome to Your ADA cover letter
The ADA Channel – A Guide to Checking Your Blood Sugar booklet by ADA
The ADA Channel – A Guide to the ADA Standard of Care booklet by ADA
The ADA Channel – A Guide to Type 2 Diabetes and Exercise booklet by ADA
The ADA Channel – Make the Link! Diabetes, Heart Disease, and Stroke booklet by ADA
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PATIENT EDUCATION PACKET
ACKNOWLEDGEMENT FORM
 Heart Failure Packet which includes
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Micromedex Congestive Heart Failure printout of patient’s current medications
Home Med Schedule
Weight Log to monitor weight
Understanding Heart Failure booklet by Krames
Living Heart Smart
Conserving your Energy with Heart Failure tear off sheet by Krames
Reading Food Labels to Limit Salt tear off sheet by Krames which addresses diet
Heart Failure Zones: Warning Signs of a Flare-Up tear off sheet by Krames which addresses
symptoms worsening
Low Salt Eating tear off sheet by Krames
Heart Failure Warning Signs of a Flare Up tear off sheet by Krames ( is this the same as the
other one? - Heart Failure Zones: Warning Signs of a Flare-Up tear off sheet by Krames)
Patient’s next appointment is___________.
 Ischemic Stroke Packet
 Care Notes – Ischemic Stroke
 Care Notes – Hemorrhagic Stroke
 Let’s Talk about Ischemic Strokes and Their Causes
 Let’s Talk about Complications after Stroke
 Let’s Talk about Stroke and Aphasia
 Let’s Talk about Changes caused by Stroke
 Let’s Talk about Emotional Changes after Stroke
 Let’s Talk about Feeling Tired after Stroke
 Let’s Talk about Risk Factors for Stroke
 Let’s Talk about High Blood Pressure and Stroke
 Let’s Talk about Stroke, TIA and Warning Signs
 Let’s Talk about Lifestyle Changes to Prevent Stroke
 Let’s Talk about Stroke and Rehab
 Let’s Talk about Living at Home after Stroke
 Let’s Talk about Anticoagulants and Antiplatelet Agents
 Let’s Talk about Driving after Stroke
My signature indicates that I have received the indicated Patient Education packet and been
allowed to ask questions regarding the contents.
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Signature of Patient/Family
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Date
Time
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Signature of Nurse Giving Packet
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Date
Time