Printable builder · Portrait · 1 page

The Self-Prescription

A prescription pad where you're both the patient and the prescribing physician. An intake box takes the chief complaint — the thing that's actually wrong, said out loud. Then three Rx lines written like medication, because they are: "One 20-minute walk, outdoors — twice daily — with or without motivation," each with a SIG line, a duration, a 14-dose adherence strip, and a write-in line for reported effects. The side effects are fixed in ink (may include improved mood, earlier bedtimes, and unsolicited energy; if symptoms of wellbeing persist, continue treatment), a warning box names what usually makes you quit the regimen, and the signature line is yours — M.D., Me Deciding. Refills: unlimited. No pharmacist required.

Best for
Writing down the three things you already know would help — in doses small enough to actually take.
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Composed
A still life that evokes the The Self-Prescription

Customize

Build your self-prescription

Step 01 · Intake

Patient and chief complaint.

Step 02 · The prescription

Three remedies, written like medication.

Every remedy prints with a SIG line, a 14-dose adherence strip, and a "reported effects" write-in line.

Step 03 · The fine print

Warning and signature.

Step 04 · Print

Paper and download.

Name the complaint.

No account required. No data saved.

Preview

Filled example
Blank layout
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