Chronic Disease Management Plan - Seniors
Personal Information
Full Name
Date of Birth
Contact Number
Emergency Contact Name & Number
Primary Diagnosis
Chronic Condition(s)
Date of Diagnosis
Healthcare Providers
Provider
Specialty
Contact
Current Medications
Medication
Dosage
Schedule
Prescribing Doctor
Management Goals
Short-Term Goals
Long-Term Goals
Self-Monitoring
What to Monitor
How Often
Lifestyle & Support
Dietary Guidelines
Physical Activity Recommendations
Social/Family Support
Follow-Up & Appointments
Date
Purpose
Provider
Notes