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Chronic Condition Assessment Form

PLEASE USE THE TAB BUTTON OR MOUSE TO MOVE BETWEEN FIELDS ON THE SCREEN - PRESSING ENTER WILL SUBMIT THE REQUEST

(*Required Fields: Your Chronic Condition Assessment cannot be submitted unless these fields are completed.*)

Participant Information:

Your Name First/Last: (*)
Date of Birth: (*)

Employee Name: (*) Employer: (*)

Member ID: (*) Relationship to Insured: Employee Spouse Child

Insured Address:

City/State/Zip:

Best way to contact you:

Telephone Number: (*) home work other

Email Address: (*)

Please check all medical conditions that apply and indicate the month and year you were diagnosed:

Asthma /

Heart Attack /

Cancer /

High Cholesterol /

COPD or Emphysema /

High Blood Pressure /

Diabetes: Type I or Type II /

Congestive Heart Failure /

Other Medical Conditions

Date Diagnosed /

**see additional questions below regarding medical conditions.

Physician Name First/Last:

Month/year last appointment: / Month/year next appointment: /

Do you smoke? yes no

If yes, indicate Pack/day:

What is your Blood Pressure: Your height in inches: Your weight in pounds:

What is your Cholesterol: Month/year of flu shot: / Month/year of pneumonia vaccine: /

How often do you exercise? What type of exercise is done?

Have you ever had nutritional counseling? yes no

If yes, when?

Please list all medications and does if known, include all over the counter medications (example: aspirin and vitamins)

ASTHMA:

Do you have a peak flow meter? yes no

If yes, how often do you use it?

Do you know your personal best zones? yes no

Do you have a written treatment plan? yes no

How often do you use your rescue inhaler?

How many times per month do you wake with difficulty breathing?

COPD or EMPHYSEMA:

Do you have a peak flow meter? yes no

If yes, how often do you use it?

Are you on oxygen? yes no

If yes, what type of system?

When do you use it?

Do you have a metered dose inhaler? yes no

Please indicate any pulmonary function results you are aware of:

CORONARY ARTERY DISEASE, HEART:

Do you have chest pain/angina? yes no

If yes, how often and what relieves it?

Do you experience shortness of breath? yes no

Do you have pain in your legs? yes no

If yes, please describe it?

DIABETES:

Do you have a working glucometer? yes no

How often do you test your blood sugar?

What was your last HbA1C result?

How often do you have an HbA1c?

Do you have a yearly eye exam? yes no

Date of last exam:

Do you have a yearly foot exam? yes no

Date of last exam: