Inside the Survivor’s Guide

Survivor Clinical Summary Form

Have the important clinical details of your care all in one place!

Our AFE Survivor Clinical Summary is a two-page editable PDF document designed to summarize the most significant aspects of your clinical care to better assist you in understanding what happened to your body.

You can ask your OBGYN, Midwife, or another primary healthcare provider to help you complete it. While they may not have some of the details in their charts, most can access your medical records and complete a good portion of the form. If they are unable to assist with that request, you may also use this as a guide when reviewing your medical records.

The summary form also serves as a great way to inform other healthcare providers in the continuity of your care such as follow-up visits with specialists or mental health providers. It aims to minimize the triggers associated with retelling the event and gives healthcare providers a quick and simple format to get up to speed on what you experienced. Simply provide it to them at your follow-up appointment or email/fax/mail to them prior to your appointment.