ANNEX C

PHILPEN RISK ASSESSMENT FORM (REVISED 2022)

Adults ≥20 years old

Name of Health Facility: Date of Assessment:

I. PATIENT’S INFORMATION

Patient Name: (SURNAME, Given Name, Middle Name) Age Sex Birthdate:

PHIC No.: Civil Status: Religion Contact No.

Patient's Address:

Persons with Disability ID Card No., if applicable: Employment Status: [ ] Employed [ ] Unemployed [ ] Self-employed

[ ] IP [ ] Non-IP Ethnicity:

II. ASSESS FOR RED FLAGS

2.1 Chest Pain [ ] Yes [ ] No

2.2 Difficulty of Breathing [ ] Yes [ ] No

2.3 Loss of Consciousness [ ] Yes [ ] No

2.4 Slurred Speech [ ] Yes [ ] No

2.5 Facial Asymmetry [ ] Yes [ ] No If YES to ANY, REFER IMMEDIATELY to a Physician

for further management and/or referral to the next level
2.6 Weakness/ Numbness on arm of left on one [ ] Yes [ ] No of care
side of the body

2.7 Disoriented as to time, place and person [ ] Yes [ ] No

If ALL answers are NO, proceed to Part III.
2.8 Chest Retractions [ ] Yes [ ] No

2.9 Seizure or Convulsion [ ] Yes [ ] No

2.10 Act of self-harm or suicide [ ] Yes [ ] No

2.11 Agitated and/or aggressive behavior [ ] Yes [ ] No

2.12 Eye Injury/ Foreign Body on the eye [ ] Yes [ ] No

2.13 Severe Injuries [ ] Yes [ ] No

III. PAST MEDICAL HISTORY

3.1 Hypertension [ ] Yes [ ] No

3.2 Heart Diseases [ ] Yes [ ] No

3.3 Diabetes [ ] Yes [ ] No

3.4 Cancer [ ] Yes [ ] No

3.5 COPD [ ] Yes [ ] No

3.6 Asthma [ ] Yes [ ] No

3.7 Allergies [ ] Yes [ ] No

3.8 Mental, Neurological, and Substance-Abuse [ ] Yes [ ] No

Disorders
3.9 Vision Problems [ ] Yes [ ] No

3.10 Previous Surgical History [ ] Yes [ ] No

3.11 Thyroid Disorders [ ] Yes [ ] No

3.12 Kidney Disorders [ ] Yes [ ] No

IV. FAMILY HISTORY

4.1 Hypertension [ ] Yes [ ] No

4.2 Stroke [ ] Yes [ ] No

4.3 Heart Disease (changed from “Cardiovascular”) [ ] Yes [ ] No

4.4 Diabetes Mellitus [ ] Yes [ ] No

4.5 Asthma [ ] Yes [ ] No

4.6 Cancer [ ] Yes [ ] No

4.7 Kidney Disease [ ] Yes [ ] No

4.8 1st degree relative with premature coronary [ ] Yes [ ] No

disease or vascular disease (includes “Heart
Attack”)

4.9 Family members having TB in the last 5 years. [ ] Yes [ ] No

4.10 Mental, Neurological and Substance Abuse Disorder. [ ] Yes [ ] No

4.11 COPD [ ] Yes [ ] No

V. NCD RISK FACTORS

5.1 Tobacco Use [ ] Q1 Never Used (proceed to Q2) If YES to Q2-Q4, follow the tobacco cessation protocol
(5As) and use Form 1. Tobacco Cessation Referral
[ ] Q2 Exposure to secondhand smoke Protocol, if needed.
[ ] Q3 Former tobacco user (stopped smoking >1 year)

[ ] Q4 Current tobacco user (currently smoking or stopped smoking

<1year)

*remove option: number of packs used in smoking*

5.2 Alcohol Q1. [ ] Never Consumed [ ] Yes, drinks alcohol If NO, congratulate the patient. The patient is at a lower
Intake risk of drinking alcohol.

If YES, proceed using AUDIT SCREENING TOOL (Form

2) to assess alcohol consumption and alcohol problems.

If YES, provide brief advice and/or extended brief advice.

The patient is on the higher risk category level of drinking
Q2. Do you drink 5 or more standard drinks for men, and 4 or more
or in harmful use of alcohol.
for women (in one sitting/occasion) in the past year ? [ ] Yes [ ] No

5.3 Physical Does the patient do at least 2.5 hours a week of moderate-intensity If NO or patient does not reach the recommended
Activity physical activity? hours/week off moderate-intensity physical activity, give
lifestyle modification advice following Annex 1. Healthy
[ ] Yes [ ] No Lifestyle Module.
5.4 Nutrition and Q1 Does the patient eat high fat, high salt food (processed/ fast food If YES to the question, give lifestyle modification advice
Dietary following Annex 2. Nutrition Practice Guidelines for Health
Assessment such as instant noodles, burgers, fries, dried fish), "ihaw-ihaw/fried Professionals in the Primary Care Screening
(e.g.

isaw, barbecue, liver, chicken skin) and high sugar food and drinks
(e.g.

chocolates, cakes, pastries, softdrinks) weekly? [ ] Yes [ ] No

5.5 Weight (kg) 5.6 Height (cm)

5.7 Body Mass Index (wt.[kgs]/ht.[cm]/ht.[cm] x 10,000): 5.8 Waist Circumference (cm): F <80cm M<90

5.9 Blood Pressure (mmHg):

VI. RISK SCREENING

6.1 Hypertension/ Blood Sugar (write NA FBS Result Date Taken:

Diabetes/ if not applicable)
Hypercholesterolemia RBS Result
/ Renal Diseases
CHECK if DM clinical symptoms are present:

[ ] Polyphagia [ ] Polydipsia [ ] Polyuria

Lipid Profile Total Cholesterol : Date Taken:

HDL:
LDL:

VLDL:

Triglyceride:

Urinalysis/ Urine Protein: Date Taken:

Dipstick Test
Ketones: Date Taken:

6.2 Chronic CHECK all applicable: If YES to any of the symptoms, obtain peak expiratory flow rate
Respiratory Diseases (PEFR). Give inhaled salbutamol, then repeat after 15 minutes.
(Asthma and COPD)
[ ] Breathlessness (or a "need for air")
Result:
[ ] Chronic cough
[ ] >20% change from baseline (consider Probable Asthma)
[ ] Sputum (mucous) production
[ ] <20% change from baseline (consider Probable COPD)
[ ] Chest tightness*

[ ] Wheezing*

* These symptoms may be episodic or seasonal, vary over

time and intensity and are worse during night and early
morning

VII. MANAGEMENT

Lifestyle Modification [ ] Yes

[ ] No

Medications:
a. Anti-Hypertensives [ ] Yes [ ] No
b. Oral Hypoglycemic Agents/Insulin [ ] Yes [ ] No

Date of Follow-up:

Remarks: