Chronic Disease Management Checklist
Patient Name: Jackie Tillman
Contact Information: jackie@you.mail | 222 555 7777
Healthcare Provider: [YOUR COMPANY NAME]
Address: [YOUR COMPANY ADDRESS] | Email: [YOUR COMPANY EMAIL]
Date Created: January 1, 2050
Next Review Date: June 1, 2050
Checklist Sections
1. Medical Appointments
Task | Frequency | Due Date | Completed |
|---|
Schedule annual physical | Yearly | January 15, 2050 | ☐ |
Blood pressure check | Monthly | February 1, 2050 | ☐ |
HbA1c test (diabetes) | Quarterly | March 10, 2050 | ☐ |
2. Medication and Treatment Plan
Task | Details | Time | Completed |
|---|
Refill medications | [Insert medication] | By February 10, 2050 | ☐ |
Administer insulin dose | As prescribed | Daily | ☐ |
Physical therapy sessions | Twice weekly | Ongoing | ☐ |
3. Lifestyle and Symptom Monitoring
Task | Goal | Tracking Start Date | Completed |
|---|
Record blood sugar levels | 80-130 mg/dL (fasting) | January 1, 2050 | ☐ |
Track exercise routine | 30 mins/day | January 5, 2050 | ☐ |
Monitor symptoms | Note unusual fatigue | Ongoing | ☐ |
4. Emergency Preparedness
Action | Details | Completed |
|---|
Update emergency contact | Add caregiver details | ☐ |
Create medication list | Include dosage/frequency | ☐ |
Call to Action
Stay proactive in managing your chronic condition! If you need assistance or have questions, reach out to [YOUR COMPANY NAME] at [YOUR COMPANY EMAIL] or call [YOUR COMPANY NUMBER]. Together, we can ensure better health and well-being.
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