Here are samples of Prescription pads for self-management courses that you can modify and utilize in your regions:
Samples of Prescription Pads/Referral Cards from MAOP RACs:
CDSMP Referral Card (from Mercy/Southwest RAC)
Prescription for Better Health (from St. Francis/Southeast RAC) (PDF) (DOC)
Other Samples:
DSMT Physician’s Prescription Form (from Area Agency on Aging of the Brazos Valley)
Prescription for Health (from MedStar Franklin Square Medical Center)
Put Life Back into Your Life (Care Connection for Aging Services)
Rx for Living Well (from Aging and Disability Resource Center (ADRC) of the Lakeshore)
Rx Promo – Salem Senior Services (from NH Chronic Disease Self-Management Network)
Rx Stamp (from Washington State Department of Health)