Important Points

Important Points Up to five OTC drugs can be issued

at one time. All must relate to the chief complaint or identified symptom.

Soldiers cannot use the same complaint for two consecutive self-care visits.

OTCs cannot be shared with buddies. Soldiers can use the Self-care

Program or Sick call at different times and in different situations.

If soldiers are very sick or badly hurt, they must get medical help right away and tell their Drill Sergeant.

TROOP MEDICAL CLINIC (TMC) SELF-CARE PROGRAMTREATMENT OPTIONS FOR SYMPTOMS/CONDITIONS

I am aware that I am participating in a self-care program. I understand that to properly perform self-care and safely treat any symptom(s) of conditions(s) that I may have during training I must follow the symptom evaluation charts. I also understand that I am responsible for carefully following the directions for use of any medication received through this program. I verify that I have read the self-care decision guide and the recommendations provided therein. I also verify that I am requesting treatment options(s) voluntarily. I also agree that I will not share medication with anyone and that I will be the sole user.

What allergies, to include medications, do you have?_________________________________________

What medicines are you presently taking? ______________________________________________

Print Name Print SSN DateSignature Unit: Sex: M F

INSTRUCTIONS: After reading the Soldier Health Maintenance Manual and identifying the proper treatment option(s), find the symptom(s)/condition(s) that you have on the list below. Circle it. Then follow the line across to find the treatment option(s) for your symptom(s)/condition(s). Circle the treatment you would like to receive. Request the identified treatment option(s) from the Consolidated Troop Medical Clinic Pharmacy.

Treatment requests will be limited to five items.NOTE: You can select Daytime OR Robo DM liquid but NOT

BOTH. You can select Daytime OR SudaGest, but NOT BOTH.

Green SheetSample

SYMPTOM/CONDITION: TREATMENT OPTION

Acne . . . . . . . . . . . . . . . . . . . . . . . . Medication (Benzoyl Peroxide)Allergies & Hay Fever . . . . . . . . . . . . . . . .SudaGest Decongestant

(Pseudoephedrine)*Athletes Foot . . . . . . . . . . . . Miconazole Nitrate Antifungal CreamBlisters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mole Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Band-Aid . . . . . . . . . . . . . . . . . . . . . . Bacitracin Antibiotic Ointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Baby Powder (Talc)Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . Genasoft (Ducosate)Cough with congestion . . . . . . . . . . . . . . . . . . . . . . . . . . . Daytime*Cough (dry) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Robo DM liquid*Cut or Scrape . . . . . . . . . . . . . . . . . Bacitracin Antibiotic Ointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Band-AidDiarrhea . . . . . . . . . . . . . . . . . . . . . . . . Anti-Diarrheal (Loperamide)Earache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ibuprofen TabletsHeadache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ibuprofen TabletsHeat Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Baby Powder (Talc)Insect Bite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Calamine Lotion . . . . . . . . . . . . . . . . . . Cortaid Cream (Hydrocortisone)Jock Itch . . . . . . . . . . . . . . . Miconazole Nitrate Antifungal Cream . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Baby Powder (Talc)Muscle Pain & Inflammation . . . . . . . . . . . . . . . .Ibuprofen TabletsNasal or Sinus Congestion (without cough) . . . . . . . . . . SudaGest

Decongestant (Pseudoephedrine)*Poison Ivy/Oak/Sumac . . . . . . . . Cortaid Cream (Hydrocortisone)PreMenstrual Syndrome . . . . . . . . . . . . . . . . . . . Ibuprofen TabletsRingworm . . . . . . . . . . . . . . Miconazole Nitrate Antifungal CreamRunny Nose or sneezing . . . . . . . . . . . . . SudaGest Decongestant

(Pseudoephedrine)Sore Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CepacolUpset Stomach . . . . . . . . . . . . . . . . . . . . . . . . Maalox Antacid PlusVaginitis . . . . . . . . . . . . . . . . . . . . . . Gyne-Lotrimin (vaginal insert)

YELLOW SHEETSelf-care Program Evaluation

(Program Participant—Soldier)InstructionsPlease complete Part 1 and Part 2.

Your responses are very important to the Self-care Program. This information is completely confidential and will only be used to improve the program. Please write any additional comments at the bottom of the page. Return the completed form to the proper pick-up location. Thank you.

Part 1Date: ___/___/___Installation: ______________________Unit: ______________________________MOS: ______________

Please circle one response for each of the following: Age: 18 – 19 – 20 – 21 – 22 – 23 – 24 – 25 – Over 25 Sex: M F

Highest education level completed: GED – High school – Some college – College graduate

Yellow Sheet: Part 2 Please circle one response for each of the following questions. If

not sure, leave that question blank.1.  I used the Self-care manual at least once to take care of myself.

Yes No 

2.  I made at least one clinic visit for Self-care using the Green Sheet.Yes No

3.   I made at least one clinic visit for regular Sick call. Yes No

4.   The Self-care Program helped me to avoid missing training time at least once. Yes No

5.  I would feel comfortable following the Self-care steps in the manual if I needed to. Yes No 

6.  The Self-care Program is a valuable benefit for my own health. Yes No

7. The Self-care training and manual taught me how to take better care of myself. Yes No

8.  When I can, I prefer to use the Self-care Program instead of regular Sick call. Yes No

9. The training and manual helped me decide whether to use Self-care or regular Sick call. Yes No

  10.  The Self-care Program should be available to all soldiers

Yes No

Drill Sergeant’s Role Ensure soldiers attend the self-

care class. Remind the soldier to follow the

Self-care Program procedures. Distribute the green sheet as

requested by soldier.– Green sheets are only to be

used by soldiers who have completed the self-care class.

Distribute and collect the yellow sheets at the end of the training cycle for each unit.

Questions?