Free Chronic Disease Management Checklist Template
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.
