Care Plan Questionaire

Completing this questionaire, will assist your health professional to create a patient focused care plan for you.

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Knowledge of Condition

What do you understand about your medical condition/s ?

What does your family/carer understand ?

Knowledge of Treatment

What do you know about your treatment ? What are the side effects ? What will happen if your treatment stops ? What other options do you have ? What does your family/carer understand about your treatment ?

Medications and Treatment Management

What might stop you taking your treatment ? This might be lack of understanding, cost , side effects. What other vitamins, supplements or social drugs do you take ?

Sharing in Discussions

How involved do you feel in making decisions about your health care with your health professional ? Is there anyone else who makes decisions for you ?

Accessing Services

How do you get the services you need to manage your health ? How do these services fit in with your culture, values and beliefs ? How confident are you dealing with health professionals to get these services ? Is there anything else that stops you from getting these services ?

Attending Appointments

What prevents you from attending your appointments ? ie transport, cost, physical disability

Symptom Monitoring

What are early warning signs or symptoms that you need to check and write down for your condition ? ie shortness of breath , pain, sugars, weight Why is it important to check for early warning signs or symptoms ? How often do you check and write these signs or symptoms down ? What stops you from doing this ?

Response and Symptom Management

What do you do to manage your early warning signs and symptoms ? What stops you from taking recommended action ? Do you have a written action plan ? How is your family/carer involved ?

Managing Impact of the Condition on Physical Activity

What activities have become more difficult to do ? ie showering, walking, household duties What things can you no longer do ? How much does your health condition interfere with you going out of your home ? How do you manage these aspects of your condition ?

Managing Impact of the Condition on Emotions and Spiritual Well-Being

Do you ever feel as though the effort of daily activities is too much for you ? ie feeling tired , cant be bothered Does your illness ever get you down ? How do you feel about your life at the moment ? How does your illness affect your spiritual well-being ?

Managing Impact of the Condition on Social Aspects of Life

Tell me about the people who support you. How does your condition affect the way you mix or socialise with other people ( ie other friends, family members ) What aspects of your social life would you like to change ? How does your condition/s impact on your ability to maintain work/hobbies ?

Healthy Lifestyle

What do you do to stay as healthy as possible ? What things do you do that make your health worse ? ie alcohol, smoking, diet , stress, inactivity, drugs and gambling What aspects of your lifestyle would you like to change ?

Using this information what goals do you have for your health and well being ? Consider these in the context of SMART Goals and try to establish 3 goals for the next 12 months. They might be about making change to your levels of exercise, diet, sleep, smoking , alcohol use, more social outings, preparing to change employment. Whatever is relevant to you and your life. At your appointment to establish your Health Plan these goals will be discussed and further defined.

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Care Plan Questionaire

Completing this questionaire, will assist your health professional to create a patient focused care plan for you.

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