ght: normal;
font-style: normal; text-decoration: none;">Each
symptom evaluation chart has a suggested time frame for using self-care
measures. 
The
time frame is underlined and in italics.
If
you dont start to get better within the suggested time frame, see a
health care provider.
If
at any time you think your minor illness is getting worse, see a health
care provider. 

TROOP MEDICAL CLINIC (TMC) SELF-CARE PROGRAM 

TREATMENT 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   Date

Signature   
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 Sheet

Sample

SYMPTOM/CONDITION:         TREATMENT OPTION

Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medication
(Benzoyl Peroxide)

Allergies & Hay Fever . . . . . . . . . . . . . . . . . . . .SudaGest
Decongestant   (Pseudoephedrine)*

Athletes Foot . . . . . . . . . . . . . . . . Miconazole Nitrate Antifungal
Cream

Blisters . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 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-Aid

Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . Anti-Diarrheal
(Loperamide)

Earache . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . Ibuprofen Tablets

Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . Ibuprofen Tablets

Heat Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . Baby Powder (Talc)

Insect Bite . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . Calamine Lotion

                  
. . . . . . . . . . . . . . . . . . . . . . Cortaid Cream (Hydrocortisone)

Jock Itch . . . . . . . . . . . . . . . . . . . Miconazole Nitrate
Antifungal Cream

                
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Baby 
Powder (Talc)