GP Care Plan

GP Care Plan  
Patient Details:  
Name: Mr. Jordan

1. Medical Conditions (Chronic or Complex):  
Type 2 Diabetes Mellitus  
Hypertension  
Dyslipidemia

2. Relevant History:  
Patient is managing type 2 diabetes with metformin and hypertension with ramipril. Recent family history includes a younger brother newly diagnosed with diabetes. Patient has been working on lifestyle modifications including diet and increased physical activity.

3. Patient Needs, Goals, and Preferences:  
Maintain blood glucose control with HbA1c under 7%  
Achieve blood pressure target under 130/80 mmHg  
Reduce LDL cholesterol to below 2.0 mmol/L  
Incorporate dietary changes focusing on low sodium and high fiber intake, and increase physical activity including walking and light strength training

4. Planned Management and Actions:  
Action/Service	Responsible Provider	Timeframe  
Repeat laboratory tests including HbA1c, fasting glucose, lipid panel	General Practitioner	In 3 months  
Referral to dietitian for personalized nutritional guidance	General Practitioner	As soon as possible  
Continue current medications (metformin and ramipril)	General Practitioner	Continuous  
Patient to maintain blood glucose log and bring to next appointment	Patient	Next visit

6. Patient Agreement and Understanding:  
☐ Plan discussed and agreed with the patient  
☐ Copy offered to patient  
☐ Consent obtained to share with involved providers

Date: 2026-01-23  
GP Signature: ______________________  
Patient Signature: __________________

7. Review Plan:  
Next review due: 3 months from today  
☐ Schedule follow-up appointment