Chronic Care Monthly Check-in
Between appointments: symptoms, self-management confidence, and what changed.
4 questions · 1 page · about 1 minute to answer · fully editable after you start
Chronic conditions are managed in the months between appointments, invisibly. This monthly check-in gives the care team eyes on that gap: symptom trend, self-management confidence, medication routine holding or slipping, and the changes – new symptoms, life events, other prescriptions – that should trigger a call rather than wait for the next slot.
Route worsening-trend responses to a nurse callback list; the check-in takes the patient about a minute and catches the deteriorations that otherwise arrive via the emergency department.
Replace [local emergency number, e.g. 000] and [local crisis line, e.g. Lifeline on 13 11 14] in its opening note with the services where your respondents live, before you share it: the numbers shown are Australia's. The Collect tab lists both until they are changed.
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Page 1
This month with your condition
This monthly check-in asks how you are managing your condition. Your answers help your care team see how you are going between appointments. It takes about 1 minute.
This form is not an emergency service. If you need urgent medical help or are in immediate danger, call [local emergency number, e.g. 000]. For crisis support, call [local crisis line, e.g. Lifeline on 13 11 14].
Q1.Compared to last month, your symptoms are...*
- Better
- About the same
- Somewhat worse
- Significantly worse
Q2.How confident are you managing the condition day to day?*
Q3.How has your medication routine held up?
- Solid
- Occasional misses
- Slipping
Q4.Anything new - symptoms, medications, life changes - your care team should know?
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