Chronic Disease Home Visit Monitoring Checklist
Patient Name
Date of Visit
Disease/Condition
Home Address
Contact Number
Family/Caregiver Present
Vital Signs
Blood Pressure (mmHg)
Pulse Rate (beats/min)
Temperature (°C)
Respiratory Rate (breaths/min)
Blood Sugar (if diabetic)
SpO₂ (%)
Assessment
Symptoms Since Last Visit
Current Medications
Medication Adherence
Good
Fair
Poor
Any Side Effects Noted
Physical Examination
Education/Counseling Provided
Referrals/Follow-up Needed
Next Visit Date
Health Worker/Visitor Name
Signature