NCD HIGH-RISK ASSESSMENT

NCD HIGH-RISK ASSESSMENT

ID No. (Community Case Finding Form) ID No.
(Community Case Finding Form)
Date of Assessment: Birth Date: Age:
Date of Assessment: Birth Date: Age:

Name: Civil Status: Sex: Name: Civil Status: Sex:

S M C W M F S M C W M F
Address: Contact Numbers: Address: Contact Numbers:

Occupation: Educational Attainment: Occupation: Educational Attainment:

Family History Smoking (Tobacco/Cigarette) Family History Smoking (Tobacco/Cigarette)

Does patient have 1st degree Never smoked Stopped > a year Does patient have 1st degree Never smoked Stopped > a year
relative with: Current smoker Stopped < a year relative with: Current smoker Stopped < a year
Passive Smoker Passive Smoker
Hypertension Yes No Hypertension Yes No
Stroke Yes No Alcohol Intake Stroke Yes No Alcohol Intake
Never consumed Yes, drinks alcohol Never consumed Yes, drinks alcohol
Heart Attack Yes No Heart Attack Yes No
Diabetes Yes No Excessive Alcohol Intake Diabetes Yes No Excessive Alcohol Intake
Asthma Yes No In the past month, had 5 drinks in one Asthma Yes No In the past month, had 5 drinks in one
occasion Yes No occasion Yes No
Cancer Yes No Cancer Yes No
Kidney Disease Yes No High Fat/High Salt Food Intake Kidney Disease Yes No High Fat/High Salt Food Intake
Presence or absence of Diabetes Eats processed/fast foods (e.g. instant Presence or absence of Diabetes Eats processed/fast foods (e.g. instant
noodles, hamburgers, fries, fried chicken noodles, hamburgers, fries, fried chicken
Was patient diagnosed as having Was patient diagnosed as having
skin, etc.) and ihaw-ihaw (e.g. isaw, adidas, skin, etc.) and ihaw-ihaw (e.g. isaw, adidas,
diabetes? etc.) weekly Yes No diabetes? etc.) weekly Yes No
Yes No Do not know Yes No Do not know
Dietary Fiber Intake: Dietary Fiber Intake:
3 servings of vegetables daily Yes No 3 servings of vegetables daily Yes No
Central Adiposity Yes No Central Adiposity Yes No
2-3 servings of fruits daily Yes No 2-3 servings of fruits daily Yes No
Waist circumference (cm) Waist circumference (cm)
Physical Activity Physical Activity
Does at least 2 ½ hours a week of moderate- Does at least 2 ½ hours a week of moderate-
Raised BP Yes No intensity physical activity Yes No Raised BP Yes No intensity physical activity Yes No

Systolic 1st reading Systolic 1st reading

Action: Action:
Diastolic 1st reading Referred to health center Diastolic 1st reading Referred to health center

Systolic 2nd reading Date & Time: _____________________ Systolic 2nd reading Date & Time: _____________________

Diastolic 2nd reading Given Health Information Diastolic 2nd reading Given Health Information

/ Average Blood Pressure Assessment done by: / Average Blood Pressure Assessment done by: ___________________
Printed Name and Signature Printed Name and Signature