Date completed

Chronic Disease Management - Patient Care Treatment Forms

Date of Service of CDM Claim

Please select the form(s) you would like to complete:

Coronary Artery Disease Patient Care Treatment Form

Diabetes Patient Care Treatment Form

Congestive Heart Failure Patient Care Treatment Form

Hypertension Patient Care Treatment Form

Physician Information

Physician surname

Physician Given Name

Billing Number

Patient Information

Patient surname

Patient Given Name

Patient Sex M F

Date of birth

Registration #

Personal health ID #

System of units

Imperial Metric

Weight (lbs)

Height

Feet

Inches

Weight (kg)

Height (cm)

Blood Pressure

Blood Pressure Measurement

Target <140/90 or <130/80 with renal disease and/or diabetes

N/A - Patient Age < 18

Lipid Profile (patients age from 18 to 74 years except for Diabetes Management: patients age 74 years and under)

LDL

Target <2.0 mmol/L

Non HDL Chol

Target <2.6 mmol/L

TC/HDL

Target <4.0

Date Completed

N/A - Patient on statins

N/A - Patient has low cardiovascular risk (Hypertension only)

Coronary Artery Disease Patient Care Treatment Form

Lipid reduction counseling (for patients from 18 to 74 years of age, with LDL levels greater than 2.0 mmol/L or non HDL Chol Level greater than 2.6 mmol/L or prescribed with lipid lowering medication).

Has lipid reduction counseling been performed?

Yes Not required

Diabetes Patient Care Treatment Form

Choose one of the following

Foot examination Management of document peripheral nephropathy

Date Completed

N/A - Bilateral Amputation

HGB A1C test

Target <=7 %

The following was performed

Fundoscopic examination Referral for a fundoscopic examination Exam not performed, no referral given

Select the option(s)

OPHTHAL

OPHTOM

Select the reason(s)

Contraindicated

Not tolerated

Financial barrier

Patient refused

N/A - Patient Age <15

N/A

Nephropathy screening

Was Nephropathy screening completed?

Yes No

ACR - Target M: <2.0, F: <2.8 mg/mmol/L

eGFR - Target >60 ml/min

N/A - Patient Age < 12 Years or Patient Age > 74 Years

N/A - Pre-existing documented nephropathy

Congestive Heart Failure Patient Care Treatment Form

Has the patient been treated with ACE-I or ARB?

Yes No

Please specify

ACE-I ARB

Select the reason(s)

Contraindicated

Not tolerated

Financial barrier

Patient refused

Left Ventricular Ejection Fraction (LVEF) > 40%

Hypertension Patient Care Treatment Form

Test to detect renal dysfunction (Patient Age: 18 to 74 years)

eGFR

eGFR Target > 60 mL/min

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