When?

Duration

Diagnosis
How? Diagnostic Test?

Non Pharmacological (Conservative) Relevant social hx eg. Diet

Dosage prescribed

Pharmacological

Dosage taken?

Yes

Management Cost?

Follow up Frequency? Compliant?

No Why? Missed TCU?

Not Free Travel?

Well controlled
Chronic Illness History Flow
Control
Poorly Controlled Why?

Has diabetes led to any other health problems for

Disease
you?
Complications

Drug S/E Does the medication give you any side effects so far?

Why do you think you developed diabetes?

Idea Why do you think your asthma is poorly controlled?

Do you think your asthma is poorly controlled?

Perspective

Function How has this affected your daily life? Work?

Is there anything else I can help you with besides an

Expectation
MC for today?