DA form 4700 template - U.S. Army



|PATIENT/FAMILY TEACHING FORM |

|(OUTPATIENT) |

|Documentation codes |

|LEARNER: |METHOD: |EVALUATION: |

|Pt =Patient |V = Videotape G = Group |V = Verbalize instruction |

|Sp = Spouse |1 =1:1 Discussion O = Other |D =Demonstrates : no assistance needed |

|M = Mother |D =Demonstration |DP = Demonstrates w/physical assistance |

|F = Father |A = Audio-tape |DV = Demonstrates w/verbal assistance |

| |P = Printed Instruction |NR = Needs reinforcement |

| | |N = No evidence of learning |

|DATE |LEARNER |EDUCATION NEEDS |METHOD |EVALUATION |SIGNATURE |

| | |Asthma “Survival Skills” | | | |

| | |1. Identify early warning signs of an asthma | | | |

| | |attack |V/D/P |V/D | |

| | |2. Demonstrate the correct technique for | | | |

| | |using a press and breathe inhaler with and |V/D/P |V/D | |

| | |without spacer | | | |

| | |3. Identify quick relief and long term | | | |

| | |controller medications |V/D/P |V/D | |

| | |4. Demonstrate correct techniques for using | | | |

| | |a peak flow meter |V/D/P |V/D | |

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