NCD HIGH-RISK ASSESSMENT

(Community Case Finding Form) ID No.

NCD HIGH-RISK ASSESSMENT ID No.
(Community Case Finding Form)
Date of Assessment: Birth Date: Age:
Date of Assessment: Birth Date: Age:
Name: Civil Status: Sex:
S M C W M F
Address: Contact Numbers: Name: Civil Status: Sex:
S M C W M F
Occupation: Educational Attainment: Address: Contact Numbers:

Family History Smoking (Tobacco/Cigarette) Occupation: Educational Attainment:

Does patient have 1st degree Never smoked Stopped > a year
relative with: Current smoker Stopped < a year Family History Smoking (Tobacco/Cigarette)
HypertensionYesNo Passive Smoker Does patient have 1st degree Never smoked Stopped > a year
StrokeYesNo
Alcohol Intake relative with: Current smoker Stopped < a year
Heart AttackYesNo
Never consumed Yes, drinks alcohol HypertensionYesNo Passive Smoker
DiabetesYesNo
Excessive Alcohol Intake StrokeYesNo
AsthmaYes No Alcohol Intake
In the past month, had 5 drinks in one occasion Yes No Heart AttackYesNo
CancerYes No Never consumed Yes, drinks alcohol
DiabetesYesNo
Kidney Disease Yes No Excessive Alcohol Intake
AsthmaYes No
CancerYes No In the past month, had 5 drinks in one occasion Yes No
at/High Salt Food Intake Kidney Disease Yes No
rocessed/fast foods (e.g. instant noodles, hamburgers, fries, fried chicken skin, etc.) and ihaw-ihaw (e.g. isaw, adidas, etc.) weekly Yes No
High Fat/High Salt Food Intake
Eats processed/fast foods (e.g. instant noodles, hamburgers, fries, fried chicken skin, etc.) and ihaw-ihaw (e.g. isaw,

Dietary Fiber Intake:

Central Adiposity Yes No 3 servings of vegetables daily Yes No
Waist circumference (cm) 2-3 servings of fruits daily Yes No
Dietary Fiber Intake:
Raised BP Yes No 3 servings of vegetables daily Yes No
Physical Activity Central Adiposity Yes No
Systolic 1st reading 2-3 servings of fruits daily Yes No
Does at least 2 ½ hours a week of moderate-intensity physical activity Yes No Waist circumference (cm)
Diastolic 1st reading
Raised BP Yes No
Systolic 2nd reading Physical Activity
Systolic 1st reading
Diastolic 2nd reading Does at least 2 ½ hours a week of moderate-intensity physical activity Yes
Diastolic 1st reading
Average Blood Pressure
Action:
Systolic 2nd reading
Referred to health center Date & Time: _____________________
Diastolic 2nd reading
Given Health Information Average Blood Pressure
Action:
Referred to health center Date & Time: ___________________
Assessment done by: ___________________ Given Health Information
Printed Name and Signature
/
Assessment done by: ___________________
Printed Name and Signature
/