CHRONIC DISEASE MANAGEMENT
<CP_Type>

Patient’s Name:  <PtFullName>	Date of Birth: <PtDoB>	
Contact Details:
<PtStreet>
<PtCity>  <PtPostcode> 
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>	

Progress Notes:
<CP_Comment>

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. The patient also agrees to the involvement of other health providers and to share their clinical information without / with restrictions (identify).

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

Patient’s Name:  <PtFormalName>

TEAM CARE ARRANGEMENTS	

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 TCA offered to patient? YES	Copy / relevant parts of the TCA supplied to other providers?  	
TCA added to the patient’s records? YES
	Referral forms for Medicare allied health services completed? YES	
Date service was completed: <TodaysDate>
	Review Date: 3 Months	

Investigations:
<Ix>