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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 an endocrinologist?
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Is the patient on hospice?
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Name(s) of Specialist(s)
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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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Thyroid Gland Failure- general
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Hashimoto's thyroiditis
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Caused from surgical complications
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Obesity
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Depression
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Thyroid Cancer
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Goiter
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Thyroid nodule
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Other Chronic Conditions, please list
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Self Care
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Has pt had a nuclear med scan?
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Date of nulear med scan
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Results of nulear med scan
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Has pt had a thyroid ultrasound?
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Date of thyroid ultrasound
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Resluts of thyroid ultrasound
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TSH drawn?
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Date of last TSH
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Result of last TSH
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Compliant with medications?
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Current medications
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Side effects from medications
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If yes, what side effect(s)?
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Current weight
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Weight Goal
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Does patient check weight regularly at home?
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BMI WNL?
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Patient seeing a dietician?
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Exercise plan
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Plan for proper nutrition
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Comments
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Associated Symptoms
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Symptoms are usually well controlled
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Comments
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Abnormal Menstrual Cycles
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Comments
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Course, dry hair
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Comments
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Decreased libido
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Comments:
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Dry, rough, pale skin
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Comments
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Fatigue
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Comments
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Frequent Muscle Aches
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Comments
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Hair loss
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Comments
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Increased difficulty losing weight
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Comments
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Irritability
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Comments
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Memory Loss
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Comments
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Muscle Cramps
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Comments
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Weakness
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Comments
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Weight Gain
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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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