Care Plan Questionnaire
This form helps our care team learn more about your health so we can support you each month. Remote Patient Monitoring lets us check on your health from home and help you manage your chronic conditions.
Patient & Administrative Information
Patient Name
*
First Name
Middle Name
Last Name
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex:
Please Select
Male
Female
Other
Unknown
Primary Language:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Diabetes & Monitoring
Have you had your yearly physical?
*
Please Select
Yes
No
Not sure
Height
Please Select
3'0"
3'1"
3'2"
3'3"
3'4"
3'5"
3'6"
3'7"
3'8"
3'9"
3'10"
3'11"
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
Weight
Have you been diagnosed with High Blood Pressure?
*
Please Select
Yes
No
Not Sure
What was your last blood pressure reading? Add your highest or lowest reading
Would you like a Blood pressure device mailed to you?
*
Please Select
Yes
No
What was your last pulse reading?
Are you diabetic?
*
Please Select
Yes
No
Unsure
If diabetic, type
*
Please Select
Type 1
Type 2
Gestational
Prediabetes
Other
Do you inject insulin?
*
Please Select
Yes
No
Unsure
If yes, how many times per day do you inject insulin?
How many times daily do you check your blood sugar?
What were your last 3 blood sugar readings?
Have you ever experienced a hypo or hyperglycemic episode? (A hypoglycemic episode is when blood sugar drops below 54 mg/dL. A hyperglycemic episode is when blood sugar rises above 300 mg/dL.)
*
Please Select
Yes
No
Unsure
What other health conditions do you have?
Primary Care & Pharmacy Details
Name of Insurance for eligibility check
*
Insurance Policy Number for eligibility check
*
Upload Insurance ID Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Medicare ID is Unknow - Use SSN
Medicare MBI Number if Known
Primary Care Provider
*
First Name
Last Name
Primary Care Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Provider Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Name
*
Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medication, Cognition, Mobility & Living Situation
Are you consistent with taking your medication?
Please Select
Always
Usually
Sometimes
Rarely
Never
How is your memory?
Please Select
Excellent
Good
Fair
Poor
Very poor
Do you have trouble with balance or walking and standing on your own?
Please Select
No
Yes, sometimes
Yes, often
Yes, always
If yes, what assistance devices do you use?
Do you reside in a nursing home?
Please Select
No
Yes
Prefer not to say
Do you need help with everyday activities?
Please Select
No
Yes, occasionally
Yes, regularly
If yes, who assists you?
Safe living environment?
Please Select
Yes
Some concerns
No
Not sure
How is your vision?
*
Please Select
Excellent
Good
Fair
Poor
Very poor
Do you wear glasses?
Please Select
No
Yes
Sometimes
Not sure
How is your hearing?
Please Select
Excellent
Good
Fair
Poor
Very poor
Do you wear a hearing aid?
Please Select
No
Yes
Sometimes
Not sure
Do you have alcohol dependency?
*
Please Select
No
Yes
Prefer not to say
Have you or currently smoked or consume nicotine products?
*
Please Select
No
Yes, cigarettes
Yes, vaping
Yes, other nicotine products
Former user
Prefer not to say
Lifestyle, Safety & Clinical History
Do you have any dental issues?
*
Please Select
No
Yes
Unsure
If yes, describe your dental issues, including dentures
Do you follow a specific diet?
*
Please Select
No
Yes
Other
If other, please describe your specific diet
How often do you do physical activity throughout the week?
Have you had any falls in the past 12 months?
*
Please Select
No
Yes
Unsure
Have you been hospitalized, gone to the emergency room, or had any major surgeries within the past 6 months?
*
Please Select
No
Yes
Unsure
If yes, please describe hospitalizations, emergency room visits, or surgeries
Technology, Consent & Emergency Contact
Do you have access to WiFi, a computer, or a smartphone?
Please Select
Yes
No
Unsure
If yes, do you consent to receiving a text message to notify you of your upcoming monthly review call?
Please Select
Yes
No
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
Are you intrested in a smart pill box?
Please Select
Yes
No
Maybe
Unsure
Additional notes
Signature
*
Intake Representative or Referral By:
*
Consent/Enrollment Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: