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Pacoima Health Center
                          Family Medicine Department

                    “Making the Most Out of Your Visit”

                      Today’s Visit:   _____ / ______/ ______

1.    “I am managing my Health…...”:

      "Excellent”         “Good”         “Not Good”             “Not Sure”




2.    “What do I want to ASK my Provider today ?”




                 “Aprovechar su Visita a lo Maximo”

                     Fecha de Hoy:     _____ / ______/ ______

1.    “Manejo mi Salud ………”

      “Excelente”         “Bien”         “No muy bien”          “No estoy segura(o)”




2.    “¿Que le voy a PREGUNTAR hoy a mi proveedor?”




     ****DO NOT FILE IN CHART—Give to DM Coord******

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  • 1. Pacoima Health Center Family Medicine Department “Making the Most Out of Your Visit” Today’s Visit: _____ / ______/ ______ 1. “I am managing my Health…...”: "Excellent” “Good” “Not Good” “Not Sure” 2. “What do I want to ASK my Provider today ?” “Aprovechar su Visita a lo Maximo” Fecha de Hoy: _____ / ______/ ______ 1. “Manejo mi Salud ………” “Excelente” “Bien” “No muy bien” “No estoy segura(o)” 2. “¿Que le voy a PREGUNTAR hoy a mi proveedor?” ****DO NOT FILE IN CHART—Give to DM Coord******