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Transition Plan

Fill out this plan with your health care provider, to help you transition to being in charge of your own health

Two ways you can use this plan are:

1. Download it as a Word doc directly onto your USB flash drive, open it with Microsoft Word, fill it out, and save it to your flash drive

2. Fill out the form online (below), then print it and store the paper version in a safe place

Printable Transition Toolkits Print complete Transition Toolkit

Patient Name
Medical Record #
Primary Care Physician
Phone Number
Email
Pediatrician
Phone Number
Email
Metabolic Specialist
Phone Number
Email
Other Health Care Provider
Phone Number
Email
Emergency Contact Name & Relationship
Phone Number
Medical Findings:
Genotype/Laboratory Findings
Treatment Status
Current Medications/Treatments
Allergies/Adverse Reactions
Past Medical Concerns or Hospitalizations
Living Situation/Employment
Mental Health Status/Cognitive Status
Other Health Risks
Contract
To enhance collaboration, each person should agree on the following responsibilities:  
Metabolic Specialist will:
 • Obtain labs and tests: For example:
 • Prescribe condition-related medications:
 • Work with PCP to develop an emergency protocol:
Patient will:
 • Remember to take medications: For example:
 • Order and pick up supplies/supplements:
 • Show-up to appointments:
Primary Care Physician will:
 • Monitor patient’s general health:
 • Update metabolic specialist with important patient information:
 • Contact metabolic specialist with medical concerns: For example:
 • Other:

When you’re done filling out this Transition Plan, print it and save it in a safe place.

Congratulations! You are well on your way to being in charge of your own health.

Printable Transition Toolkits Print complete Transition Toolkit