NCACCH Service Access Form 2

NCACCH North Coast Aboriginal Corporation for Community Health

CHRONIC DISEASE MANAGEMENT PROGRAM (CDMP) GP STATUS FORM

NCACCH is seeking to gather information about Aboriginal and/or Torres Strait Islander clients participating in the CDMP. This information will assist the Health Advocate and NCACCH with monitoring the client’s health status.

Date: Client Name: GP Name: Practice Name:

Client’s Chronic Condition: Diabetes Cardiovascul Respiratory (including sleep Cancer Renal Condition ar apnea)

Complete and/or attach reports relevant to client’s chronic condition at time of consult and send back to NCACCH on 5335 1272 (fax) or [email protected]

GP to complete:

Flu Vaccine: Y / N If yes, date: Pneummo Vaccine: Y / N If yes, date: Full Adult/Child Health Check Y / N If yes, date: (715)

Diabetes Type 1 / 2 Waist Blood (Please circle) Weight: Circumference: BMI: Pressure: Lifestyle Modification: Social Emotional Wellbeing: Foot Check Visual Left Right Retinal camera / eye Conducted: Y / N acuity examination required: Y / N : Total Cholesterol (TC): LDL Cholesterol: HDL Cholesterol: mmol/L mmol/L mmol/L HBA1C: Triglycerides (TG): eGFR: % mmol/L ml/min ACR: Fasting BGL: Post-prandial BGL: mg/mmol mmol/L mmol/L ECG Conducted: Y / N If yes date:

Cardiovascular Weight: Waist Circumference: BMI: Pulse: Blood Pressure: Total Cholesterol (TC): LDL Cholesterol: HDL Cholesterol: mmol/L mmol/L mmol/L Triglycerides (TG): ACR: eGFR: mmol/L mg/mmol ml/min ECG Conducted: Y / N If yes, date:

Respiratory (including sleep apnea) Weight: Quit Smoking Education: Y BMI: Pulse: Blood Pressure: / N Temperature: Full Blood Count Conducted: Respirations: Y / N breaths/min FEV1/FVC Ratio: % FEV1: % Oxygen saturations (Sp02): % Chest x-ray completed: Y / N ECG Conducted: Y / N If yes, date:

Renal Conditions Weight: Waist Circumference: BMI: Blood Pressure: HBA1C: % Blood Glucose Level Pre-prandial: Proteinuria: Proteinuria:

D:\Docs\2018-04-30\059b9f9d6ca31c9a7f272c97eb2a5e0b.doc Reviewed February 2017 mmol/L mg/dL mg/day Haemoglobin: Hb Total Cholesterol (TC): LDL Cholesterol: g/L mmol/L mmol/L Phosphate (P04): Parathyroid hormone (PTH): Serum albumin: mmol/L g/L Bicarbonate level (HC03): Potassium (K+): mmol/L mmol/L

D:\Docs\2018-04-30\059b9f9d6ca31c9a7f272c97eb2a5e0b.doc Reviewed February 2017