Partners CAP Self-Care Management Tools

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* Form Printing from Adobe Acrobat

Table of Contents
History of the Community Access Program (CAP)


Diabetes Goal-setting contract
Patient Agreement to One Diabetes Goal (MS Word)
Diabetes Patient Questionnaire (MS Word)
Diabetes Self-Management (MS Word)

Diabetes Zones for Self-Management
ASelf-Care Stoplight (Green, Yellow, Red) Guide (MS Word)
Patient Guide for Diabetes Management (MS Word)
Tips for Diabetes Control (MS Word)
New Year Patient Letter (MS Word)

Asthma Assessment Flow Sheet (MS Word)

Asthma Action Plan
A Self-Care Stoplight (Green, Yellow, Red) Guide Asthma Questionnaire (MS Word)

Asthma Questionnaire
How do YOU think your asthma is? (MS Word)

Asthma Medical Record Templates for Initial and Follow-up Visit
Asthma Notes: Initial Assessment (2 pages) (MS Word)
Asthma Notes: - Follow-up Assessment (MS Word)
Asthma Notes: - Asthma Progress Note (MS Word)

Depression/Mental Health Flow Sheet (MS Word)

Depression Self-Care Survey
Introduction & Patient Questionnaire (2 pages)
Nine Symptom Checklist(MS Word)

Process for Managing Depression (MS Word)
Self-care Action Plan (two-sided tri-fold) (MS Word)
What Is Depression? (MS Word)
What you should know about your medication (MS Word)

Cardiovascular Self-Management (Adobe Acrobat)
Tips for Blood Pressure Control (Adobe Acrobat)

Blank Forms
CAP Application for Benefits
CAP Release and Benefits Application
CAP Welcome Letter (MS Word)
CAP re-enrollment letter (MS Word)
HIPAA Authorization Form (MS Word)
Instructions - Application for Re-Enrollment for Primary Care Benefits
Alternative Application for Health Benefits (MS Word)
Patient Financial Statement  Page 1   Page 2
Instructions - Health History
Health History scan form(Adobe Acrobat) * See note at top of page
Instructions - Adult Health Schedule
Adult Health Schedule (MS Excel)
Instructions - Data Sheet
    Data sheet (Adobe Acrobat) * See note at top of page
Partners CAP Member Satisfaction Survey (Adobe Acrobat) * See note at top of page
CAP Health Survey (SF8) (Adobe Acrobat) * See note at top of page

Measurement & Evaluation
Key Measures
Comparison Sources
Preventive Measures & Screening

Preventive Information
Alcohol Facts (MS Word)
When Smokers Quit (MS Word)