CHRONIC DISEASE MANAGEMENT
<CP_Type> 

Patient’s Name:  <PtFullName>	Date of Birth: <PtDoB>	
Contact Details:
<PtAddress>  
Home Phone: <PtPhoneH>
Work Phone: <PtPhoneWk>
Mobile Phone: <PtPhoneMob>	Medicare No.:
<PtMCNo>	
Details of Patient’s Usual GP:
<DrDetails>	Details of Patient’s Carer (if applicable):
<CP_Carer>	

Other notes or comments relevant to the patient's care planning:
<CP_Comment>

Progress Notes:
<TodaysVisit>

Past History:
<SelectedPMH>

Medications:
<SelectedRx>

Allergies:
<Reactions>

Immunisations:
<Imm>

Social History:
<SocialHx>

Family History:
<FamilyHx>

I have explained the steps and costs involved, and the patient has agreed to proceed with the service:

 ……………………………………………………………….…(GP’s Signature & Date)

Patient’s Name:  <PtFormalName>

GP MANAGEMENT PLAN	

Patient problems / needs / relevant conditions	
<CP_Problems>

Goals - changes to be achieved.	
<CP_Goals>

Required treatments and services.	
<CP_Tasks>

Arrangements for treatments/services.	
<CP_Providers>

Copy of GPMP offered to patient? YES	Copy / relevant parts of the GPMP supplied to other providers?  YES	
GPMP added to the patient’s records? YES		
Date service was completed:  <TodaysDate>
	Review Date: 3 months

Investigations:
<Ix>