1. My Green Sheet
Name: _________________________________ Physician: ____________________________
Chaplain: ______________________________ Case Manager: ________________________
My Diagnosis: _________________________________________________________________
One thing that is important to me during this hospital stay is: ___________________________
_____________________________________________________________________________
My Favorites (TV shows, music, sports,hobbies, foods, pets, family, etc.) _________________
_____________________________________________________________________________
Things that stress meout: _______________________________________________________
Things that cheer me up: ________________________________________________________
At home I use (check all that apply):
 Glasses  Contact Lenses  Dentures  Hearing Aid  Cane/Walker  Other ________
My regular sleep schedule is ______ to ______ I usually like to bathe in the  AM or  PM
Other things I’d like you to know aboutme: _________________________________________
_____________________________________________________________________________
PersonalGoals: ________________________________________________________________
My supportiverelationships/networks/outpatientproviders include(Name/Contact Info.):
1.___________________________________ 2._____________________________________
My plan to keep myself safe after discharge: ________________________________________
_____________________________________________________________________________
ImportantQuestions for my Physician or Care Team:
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________