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This tool is meant to assist individuals and/or their caregivers in keeping track of the management of their chronic condition(s). It is meant to provide a weekly snapshot or overview of their health and any concerns they may have. It is NOT meant to be a complete tool for tracking chronic disease management, nor should it replace any record-keeping a doctor or healthcare provider has given.

The information provided in this tool should is not intended to be nor should it be taken as medical advice.

Instructions: Complete this form weekly to the best of your abilities to track your management of your chronic
conditions. There may be some parts of this tool that do not apply to everyone, in which case they should be left blank