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Patient Name
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Patient DOB
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Patient PCP
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Best Phone Number to reach pt
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Date of last Office Visit
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Care Manager Name
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Date of Last IP Hospitalization
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Reason for last hospitalization
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Date of last ED Visit
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Reason for last ED Visit
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Name of Patient support at home
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Patient Insurance Plan
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CPC+ Patient?
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ACO Patient?
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Reviewed medication list w/pt or MAR
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Reviewed Allergies?
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Is the patient seeing other MDs?
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Is the patient seeing the dietician?
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Name(s) of Specialist(s)
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Is the patient on hospice?
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Is the patient on Home Health?
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Does patient live in a Nursing Home?
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Prognosis
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Newly diagnosed this year?
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Atherosclerotic coronary artery disease
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Hypertensive retinopathy
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Cardiac arrhythmia
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Left ventricular hypertrophy
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CHF
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Microvascular disease
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Depression
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Obesity
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Diastolic dysfunction
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Stroke
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ESRD
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Other Chronic Conditions, please list
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Self Care
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Checking blood pressure at home?
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Last Home BP
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Last OV Blood Pressure
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Blood Pressure Goal
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Date of last OV Blood Pressure
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Last LDL value
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LDL Goal
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Last HDL value
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HDL Goal
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Last HbA1c value
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HbA1c Goal
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Using an ACE inhibitor?
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Using a beta blocker?
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Using an ARB?
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Current Tobacco User?
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If a current tobacco user, how much and often?
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Does patient check weight regularly at home?
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Current weight
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BMI WNL?
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Weight Goal
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Plan for proper nutrition
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Plan for Exercise
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Side effects from medications
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If yes, what side effect(s)?
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Associated Symptoms
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Symptoms are usually well controlled
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Comments
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Blurred Vision
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Comments
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Calf Muscle Cramps
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Comments
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Chest pain
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Comments
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Confusion
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Comments
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Dizziness
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Comments:
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Excessive Sweating
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Comments
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Fatigue
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Comments
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Headaches
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Comments
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Light headed
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Comments
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Shortness of Breath
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Comments
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Current Status
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Personal Goal #1
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Action Steps
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Personal Goal #2
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Action Steps
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Personal Goal #3
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Action Steps
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Does patient feel goals are attainable?
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Comments:
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Date of next Care Management Visit
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