Chronic Disease Management - Patient Care Treatment Forms

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

Physician Information
Patient Information
System of units
Blood Pressure

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

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

Target <2.0 mmol/L

Target <2.6 mmol/L

Target <4.0

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?

Diabetes Patient Care Treatment Form

Choose one of the following

Target <=7 %

The following was performed
Select the option(s)
Nephropathy screening
Was Nephropathy screening completed?

Congestive Heart Failure Patient Care Treatment Form

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

If you want to keep a copy of this form, print it out before you send it.