Chronic Disease Management Check-In

Chronic Disease Management Check-In — Form Fields

This healthcare template includes 7 fields. Regular check-in form for patients managing chronic conditions to track symptoms and medication adherence. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Primary Condition Being Managed (dropdown selection, required) — options: Type 2 Diabetes, Hypertension, Heart disease, Asthma or COPD, Chronic kidney disease, Other
• Have you been taking your medications as prescribed? (multiple choice, required) — options: Yes, consistently, Mostly, with occasional missed doses, No, I have stopped or significantly changed my dosing
• How well-controlled do you feel your condition has been this past week? (1 = poorly, 5 = very well) (rating, required)
• Have you experienced any of the following this past week? (select all that apply) (checkboxes, optional) — options: Unusual fatigue, Dizziness or lightheadedness, Chest pain or palpitations, Swelling in legs or feet, Shortness of breath, None of the above
• Have you visited an emergency room or urgent care since your last check-in? (multiple choice, required) — options: Yes, No
• Any other symptoms, concerns, or updates for your care team? (long text, optional)