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CVC CARE PLAN	

Patient’s Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	

Contact Details:		Medicare or Private Health Insurance Details:	
<<Patient Demographics:Full Address>>	<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>	

Details of Patient’s Usual GP:	Details of Patient’s Carer (if applicable):	
<<Doctor:Name>>
<<Doctor:Full Address>>
Provider No: <<Doctor:Provider Number>>	Name: <<Name of of Patient’s Carer (if applicable):>>
Relationship to Patient: <<Relationship of Carer to Patient>>
Tel: <<Contact Telephone or Mobile No of Carer >>

Date of last Care Plan/GP Management Plan (if done):  <<Date of last Care Plan/GPMP>>

Other notes or comments relevant to the patient’s Management Plan: 

	

PAST MEDICAL HISTORY

<<Clinical Details:History List>>

FAMILY HISTORY 

<<Clinical Details:Family History>>

SOCIAL HISTORY 

<<Clinical Details:Social History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

<<Clinical Details:Allergies>>

Partner In Health Scale

Patient to complete this section:

1. Overall, what I know about my health condition(s) is: 	<<My knowledge of my condition(s) is >>

Where 0 is very little and 8 is a lot	Action: 	
2. Overall, what I know about my treatment including medications for my health condition(s) is:	<<What I know about my treatment and medications >>

Where 0 is a little and 8 is a lot		
3. I take medications or carry out treatment asked by my doctor/health worker:	<<I take medications or carry out treatments as asked>>

Where 0 is never, 4-5 is sometimes and 8 is always.		
4. I share in decisions made about my health condition(s) with my doctor or health worker: 	<<I share in decisions made about my health>>

Where 0 is never, 4-5 is sometimes and 8 is always.		
5. I am able to deal with health professionals to get services I need that fit with my culture, values and beliefs: 	<<I am able to deal with health workers to get service>>

Where 0 is never, 4-5 is sometimes and 8 is always.		
6. I attend appointments as asked by my doctor or health worker: 	<<I attend appts as asked by my dr of health worker>>

Where 0 is never, 4-5 is sometimes and 8 is always.		
7. I keep track of my symptoms and early warning signs (e.g. BSL, Weight, pain, mood)	<<I keep track of my symptoms / early warning signs>>

Where 0 is never, 4-5 is sometimes and 8 is always		
8. I take action when early warning signs and or symptoms get worse:	<<I take action if signs or symptoms get worse>>

Where 0 is never, 4-5 is sometimes and 8 is always		
9. I manage the effect of my health condition(s) on my physical activity: 	<<I manage my physical activities (effect of condition)>>

Where 0 is Not Well, 4-5 is Fairly Well and 8 is Very Well
		
10. I manage the effect of my health condition(s) on how I feel (i.e. emotions and spiritual well being:	<<I manage how I feel ( effect of health conditions)>>

Where 0 is not very well, 4-5 is Fairly Well and 8 is Very Well.		
11. I manage the effect of my health condition on my social life (i.e. how I mix with other people): 	<<I manage my social life (effect of condition(s) )>>

Where 0 is Not very well, 4-5 is Fairly Well and 8 is Very Well		
12. Overall, I manage to live a healthy life (e.g. no smoking, moderate alcohol, healthy food, regular physical activity, manage Stress)	<<Overall, I manage to live a healthy life (SNAP)>>

Where 0 is Not very well, 4-5 is Fairly Well and 8 is Very Well

K10 Depression Scale
Please place an X in the correct box.
Do not answer questions 3-6 if the answer to question 2 is "none of the time" in which case questions 3-6 automatically receive a score of one each.
The maximum score is 50 indicating severe distress and the minimum score is 10 indicating no distress.

In the past 4 weeks	Score	Review	
1. About how often did you feel tired out for no good reason?	<<How often did you feel tired for no reason last 4 wk>>		
2. About how often did you feel nervous?	<<How often have you felt nervous in the last 4 wks>>		
3. About how often did you feel so nervous that nothing could calm you down?	<<How often is it nothing can calm your nervousness?>>		
4. About how often did you feel hopeless?	<<How often in last 4 wks have you felt hopeless?>>		
5. About how often did you feel restless or fidgety?	<<How often do you feel restless of fidgety in last 4wk>>		
6. About how often did you feel so restless you could not sit still?	<<How often did u feel so restless you couldn't sit still>>		
7. About how often did you feel depressed? 	<<How often did you feel depressed in last 4 weeks?>>		
8. About how often did you feel that everything is an effort?	<<How often was everything an effort in the last 4 wk>>		
9. About how often did you feel so sad that nothing could cheer you up?	<<How often did u feel so sad nothing cheered u up>>		
10. About how often did you feel worthless?	<<In the last 4 wks how often did you feel worthless?>>		

K10 Score -  

Patient’s Name: <<Patient Demographics:Full Name>>

CVC CARE Plan	

What are the things that concern me?	Goals - What I need to do.	How Important is this to me?
*** Very Important
** Important
* Less Important	How will I go about reaching this goal?

Required treatments and services including patient actions	Who will help me reach this goal? 

Arrangements for treatments/services 	How am I going?
Review 3 months	How am I going?
Review 6 months	How am I going?
Review 9 months
	
1. General								
Patient's understanding of their condition	Patient to have a clear understanding of their condition and patient's role in management.		Patient education  	GP / Nurse 
Educator				

								
2. Lifestyle								
Nutrition	Maintain healthy diet		Patient education

OR 
As per Lifescripts action plan	Patient to implement
GP to monitor 
Dietitian				
Weight	Your target: BMI <   
Ideal: BMI ≤ 25 kg/m2		Monitor
Review 6 monthly

OR 
As per Lifescripts action plan	Patient to monitor
GP to review				
Physical activity	Your target:

Ideal:
Exercise at least 30 minutes walking or equivalent 5 or more days per week		Patient exercise routine

OR 
As per Lifescripts action plan	Patient to implement
GP to review
Exercise Physiologist
Personal Trainer				
Smoking	Complete cessation		Smoking cessation strategy:
Consider:
- Quit
- Medication

OR 
As per Lifescripts action plan	Patient to manage
GP to monitor and support				
Alcohol intake	Your target:
<    standard drinks per day
Ideal:
≤ 2 standard drinks per day (men)
≤ 1 standard drinks per day (women)		Reduce alcohol intake
Patient education

OR 
As per Lifescripts action plan	Patient to manage
GP to monitor and support				
3. Biomedical								
Blood pressure	Your target: < 
Ideal: 
< 130/80 mm Hg		Check every 6 months	GP / Nurse				

								

								
4. Medication								
Medication review	Correct use of medications, minimise side effects		Patient education
Review medications	GP to review and provide education				

								
5. Other								

								

								

								

								

Copy of GP Management Plan offered to patient?  <<Copy of GPMP offered to patient?>>

Copy / relevant parts of the GP Management Plan supplied to other providers?  <<Copy of GPMP supplied to other providers?>>

GP Management Plan added to the patient’s records?  <<GPMP added to patient's records?>>

Date service was completed:  <<Date service completed>>	Proposed Review Date:  <<Proposed review date (recommended 6 months)>>	

I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan.  <<Steps and costs explained, patient agreed>>

 GP’s Signature:  x_______________________________________ ________	Date: <<Miscellaneous:Date>>
   GP Name:  <<Doctor:Name>>

My Team

Provider Name	Treatment/ Service/ Goals	Address	Phone Number	Number of visits	
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