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GP Chronic Condition Management Plan

Patient: Caterina FOREMAN
Author: Dr Peter Primary
Date Authored: 25/05/2026 14:50

Patient details

Consent

Consent given to proceed with plan after discussion of the purpose, benefits, process and costs
Yes

Name
Caterina FOREMAN

Preferred pronouns
she/her/her/hers/herself

Date of birth
24/07/1970

Age
55

Sex assigned at birth
Female

Gender identity
Identifies as female gender

Aboriginal and/or Torres Strait Islander status
Neither Aboriginal nor Torres Strait Islander origin

My Aged Care

Registered for My Aged Care
No

National Disability Insurance Scheme

Registered for NDIS
No

Medicare card number

Number | Reference number | Expiry
3951333701 | 1 | 2028-08

Contact information

Home phone

0370109077

Mobile phone

0491576801

Email

caterina.foreman@my-own-personal-domain.com

Home address

Home address

Street address | City | State | Postcode
149 Farmer Cnr | Sunshine | Victoria | 3020

Carers and key contacts

Preferred contact | Role | Name | Phone | Email | Relationship to patient | Present at appointment

Yes

Contact person
Carer

Mia LEANNE BANKS

0270107520
0491574632
0270102724

Emergency Contact

Heather MACKAY

0370108075
0491578148
0370103228

Practitioner details

Name
Peter Primary

Phone

(08) 7010 5556

Email

PPP@example.org

Medicare provider number

2426621B

Clinic details

Name
Quinninup Medical Clinic

Address

Street address
24 Grande Pl

City
Quinninup

State
Western Australia

Postcode
6258

Clinical details

Problems/Diagnoses

Recorded problems/diagnoses

Condition | Clinical status | Onset date | Abatement date
Chronic lower back pain | Active | 01/01/2021 |
Gastro-oesophageal reflux disease | Active | 01/08/2013 |

New problems/diagnoses

Condition | Onset date | Comment
Uncontrolled type 2 diabetes | 25/01/2026 |
Peripheral neuropathy due to diabetes | 20/02/2026 |
Overweight | 25/11/2025 |

Adverse reaction risks

Recorded adverse reaction risks

Substance | Status | Manifestation | Comment
Latex | Active | Rash | Has reacted soon after exposure as well as a delayed reaction to latex, with a rash appearing 24 hours after exposure.

Medications (current)

Recorded medications

Medication | Status | Dosage | Indication | Comment
Panadol Osteo 665 mg modified release tablet | Active | 2 tabs PRN/TDS | Chronic lower back pain |
Panadol Osteo 665 mg modified release tablet | Active | 2 tabs PRN/TDS | Chronic lower back pain |
Esomeprazole 20 mg enteric capsule | Active | 1 tab daily | Gastro-oesophageal reflux disease | Gastroscopy 2013 - mild reflux esophagitis, H pylori negative

New medications

Medication | Dosage | Indication | Comment
Metformin hydrochloride 500 mg tablet | 1 tab BD | Uncontrolled type 2 diabetes |
Fish oil | 2 caps daily | | Self-initiated for heart health

Observations

Observations

Height

New result
165 cm

New result date
17/08/2026

Weight

New result
75.2 kg

New result date
17/08/2026

BMI (calculated)

New result
27.6 kg/m2

Waist circumference

New result
82.5 cm

New result date
17/08/2026

Pulse rate

New result
76 /min

New result date
17/08/2026

Pulse rhythm

New result
Pulse regular

New result date
17/08/2026

Oxygen saturation

New result
98 %

New result date
17/08/2026

Blood pressure

Blood pressure

Systolic
130 mm[Hg]

Diastolic
72 mm[Hg]

Date performed
17/08/2026

Substance use

Smoking status

Comment
20 cigarettes per day since 17yo

Alcohol consumption status

Comment
2 drinks, 2 days per week (on weekends)

Additional information
Family history: Mother - diabetes, stroke; Father - heart attack, depression; Paternal grandmother - breast cancer Work: Receptionist in building business

Plan

New plan or a review of an existing plan?
New

Incomplete draft plan already exists?
Yes

Conditions addressed

Condition | Onset date | Comments
Uncontrolled type 2 diabetes | 25/01/2026 |
Chronic lower back pain | 01/01/2021 |
Gastro-oesophageal reflux disease | 01/08/2013 |
Overweight | 25/11/2025 |

Goals and tasks

Problems/Needs

Uncontrolled type 2 diabetes

Hyperglycaemia

Peripheral neuropathy due to diabetes

Overweight

Goal setting

Goals | Initiator | Target date | Status | Comment
Controlled diabetes - aim HbA1c ≤7.0 and fasting BGL 4.0-7.0 | GP | 20/05/2027 | active |

Interventions and actions

Interventions/Actions | Owner | Target date | Status | Comment
Diabetic education | Caterina, diabetes educator | 20/08/2026 | Planned |
Diet education | Caterina, dietitian | 20/08/2026 | Planned |
Exercise regime | Caterina, exercise physiologist | 20/11/2026 | Planned | Aim for 150 mins moderate physical activity per week
Weight management program | Caterina, GP | 20/05/2027 | Planned | Aim for 5-10% weight loss, waist circumference <80cm
Diabetes medicine review | Caterina, GP, pharmacist | 20/08/2026 | Planned | Consider Home Medicines Review in 3-6 months
Metformin therapy | Caterina, GP, pharmacist | 03/06/2026 | Planned |
Detecting complications early | Caterina, GP, podiatrist, optometrist | 20/05/2027 | Planned | Regular screening for diabetic nephropathy, neuropathy and retinopathy

Services and treatments

Required services and treatments | Activity | Provider | Comment
Diabetes education service | Referral to diabetes nurse | Diabetes educator |
Diabetes education service | Diabetes diet education | Diabetes educator |
Dietetics service | Referral to dietitian | Dietitian |
Dietetics service | Diet education | Dietitian |
Exercise physiology service | Referral to exercise physiologist | Exercise physiologist |
Exercise physiology service | Exercise regime | Exercise physiologist |
Medicine review service | Referral to pharmacist | Pharmacist |
Medicine review service | Home medicines review | Pharmacist | Consider Home Medicines Review in 3-6 months
General practice service | Ongoing review | GP, practice nurse |

Problems/Needs

Uncontrolled type 2 diabetes

Overweight

Gastro-oesophageal reflux disease

Chronic lower back pain

Low self-esteem

Goal setting

Goals | Initiator | Target date | Status | Comment
5-10% weight loss (target weight 73.8-77.9kg) and decrease waist circumference (long term target <80cm) | GP | 20/05/2027 | active |
Comfortably wear dress purchased for niece’s wedding next year | Caterina | 20/05/2027 | active |

Interventions and actions

Interventions/Actions | Owner | Target date | Status | Comment
Low carbohydrate diet education | Caterina, dietitian | 20/08/2026 | Planned |
Reduce ratio of carbohydrates in each meal – ¼ plate carbs, ¼ plate protein, ½ plate vegetables/salad | Caterina | 20/08/2026 | Planned |
Substitute high GI for low GI carbohydrates where possible | Caterina | 20/08/2026 | Planned |
Physical activity guidance | Caterina, exercise physiologist | 20/11/2026 | Planned |
Aim for 150 mins of aerobic activity per week | Caterina | 20/11/2026 | Planned |
2-3 sessions of resistance exercise per week | Caterina | 20/11/2026 | Planned |
Management of impulse control | Caterina | 20/11/2026 | Planned | Manage impulsivity/desire to eat when not actually hungry. Consider psychology input in future

Services and treatments

Required services and treatments | Activity | Provider | Comment
Dietetics service | Referral to dietitian | Dietitian |
Dietetics service | Diet education | Dietitian |
Exercise physiology service | Referral to exercise physiologist | Exercise physiologist |
Exercise physiology service | Exercise regime | Exercise physiologist |

Completion

Consent given for sharing of information with relevant healthcare providers
Yes

Review

Appointment status
Proposed

Date
20/05/2027

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Consent given to proceed with plan after discussion of the purpose, benefits, process and costs

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Aboriginal and/or Torres Strait Islander status

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Neither Aboriginal nor Torres Strait Islander origin

# item[].item[].item[].item[].item[].answer[].valueString
Has reacted soon after exposure as well as a delayed reaction to latex, with a rash appearing 24 hours after exposure.

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Panadol Osteo 665 mg modified release tablet

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Panadol Osteo 665 mg modified release tablet

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Gastroscopy 2013 - mild reflux esophagitis, H pylori negative

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Family history: Mother - diabetes, stroke; Father - heart attack, depression; Paternal grandmother - breast cancer
Work: Receptionist in building business

# item[].item[].item[].text
New plan or a review of an existing plan?

# item[].item[].item[].item[].item[].answer[].valueString
Controlled diabetes - aim HbA1c ≤7.0 and fasting BGL 4.0-7.0

# item[].item[].item[].item[].item[].answer[].valueString
Aim for 150 mins moderate physical activity per week

# item[].item[].item[].item[].item[].answer[].valueString
Aim for 5-10% weight loss, waist circumference <80cm

# item[].item[].item[].item[].item[].answer[].valueString
Consider Home Medicines Review in 3-6 months

# item[].item[].item[].item[].item[].answer[].valueString
Regular screening for diabetic nephropathy, neuropathy and retinopathy

# item[].item[].item[].item[].item[].answer[].valueString
Consider Home Medicines Review in 3-6 months

# item[].item[].item[].item[].item[].answer[].valueString
5-10% weight loss (target weight 73.8-77.9kg) and decrease waist circumference (long term target <80cm)

# item[].item[].item[].item[].item[].answer[].valueString
Comfortably wear dress purchased for niece’s wedding next year

# item[].item[].item[].item[].item[].answer[].valueString
Reduce ratio of carbohydrates in each meal – ¼ plate carbs, ¼ plate protein, ½ plate vegetables/salad

# item[].item[].item[].item[].item[].answer[].valueString
Substitute high GI for low GI carbohydrates where possible

# item[].item[].item[].item[].item[].answer[].valueString
Aim for 150 mins of aerobic activity per week

# item[].item[].item[].item[].item[].answer[].valueString
2-3 sessions of resistance exercise per week

# item[].item[].item[].item[].item[].answer[].valueString
Manage impulsivity/desire to eat when not actually hungry. Consider psychology input in future

# item[].item[].item[].item[].text
Consent given for sharing of information with relevant healthcare providers