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My Personal Care Plan Date_____/_____/____

Name______________________________ My preferred language _______________
My arthritis diagnosis: Osteoarthritis: R Knee L Knee R Hip L Hip
Date of Weight Bearing X-Ray:_ ___/ ___/ _____ Severity Grade 2 Grade 3 Grade 4
Other conditions that may affect management of my Osteoarthritis condition None
High Blood Pressure Heart disease Diabetes Kidney disease Liver disease Peptic ulcer Indigestion
Depression or other emotional problems fall/s within the last twelve months My current weight (too much or too little)
Medicine issues that may affect management of my Osteoarthritis condition None
I take many different medicines I don’t understand why I am taking all my medicines
I have an allergy to aspirin or other antiinflammatory medicines I don’t always remember to take my arthritis medicine/s

Previous OA Surgery 1. site ______ Type of surgery _____________ 2. site _________ Type of surgery ____________
3. site ______ Type of surgery _____________ 4. site _________ Type of surgery ___________

Other Issues ____________________________________________________________________________________________

My previous osteoarthritis treatments

Names of Did it work? Side effects
medicine/treatment
Medication

Physiotherapy

Other therapies

. 10=very bad] Overall symptom score is __/10 __/10 __/10 __/10 __/10 Overall pain score is __/10 __/10 __/10 __/10 __/10 Overall function score is __/10 __/10 __/10 __/10 __/10 My self care participation score is. ____/____ mmHg ____/____ mmHg ____/____ mmHg ____/____ mmHg Overall my doctor’s or other health __/10 __/10 __/10 __/10 professional’ thinks my condition is [0=very good.. It has been suggested I have these tests It has been suggested I come back for Date __/__/__ Date __/__/__ Date __/__/__ Date __/__/__ reassessment on … . 96 = not able to participate well in my own OA health care Other scores eg MAPT __/__ __/__ __/__ __/__ My weight is…. It has been suggested I see another health professional including …. _____ Cm _____ Cm _____ Cm _____ Cm My Blood Pressure is ……. It has been suggested I use my medicines in the following way…. It has been suggested I add new medicine including ….Measuring my progress and thinking about my current osteoarthritis or general health issues My OA symptoms Overall scores Date __/__/__ Date __/__/__ Date __/__/__ Date __/__/__ [0= very good... _____Kg _____Kg _____Kg _____Kg My belly measurement is . 10=very bad] It has been suggested I reduce my risks including……... 0= excellent participation in my own OA __/96 __/96 __/96 __/96 healthcare.

Adding glucosamine 1.See a physiotherapist Overall improvement scale 7/10 Continue exercise program to play golf 3 times/week 2.5 g per glucosamine. I am using Try glucosamine for 3 months 3.My Personal Goals Summary and Progress How will I achieve my goal? How am I going? Did I have What I plan to do now any problems following Date recommendations made recommendations? __/__/___ Date of review __/__/___ Example: I want to be able 1.Follow exercise plan provided instead of once/week by my doctor or physio I saw the physio.Regular use of pain regular paracetamol and I am trial period management medication still thinking about using 4. Goal 1: Goal 2: Goal 3: Goal 4: . day (Write down reasons for not starting and discuss with your GP or specialist).

Creams. Glucosamine.My Medicine List [Simple pain relief. Anti-inflammatory medicines. Injections] Name of medicine Date started How much and how often? Date stopped or What changes were made? changes made __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ __/__/____ .

email] General Practitioner Rheumatologist Orthopedic Surgeon Allied Health Professionals and/or community health service [includes physiotherapist. podiatrist. dietician. occupational therapist.My Contact List Name and address Contact numbers [phone. fax. orthotist and others] Psychological counsellor Someone who can be called if I am in trouble .