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:

Family History Educational
Smoking Attainment:
(Tobacco/Cigarette)
Does patient have 1st degree Never smoked Stopped > a year Does patient have 1st degree Never smoked Stopped > a year
relative with: relative with:
Current smoker Stopped < a year Current smoker Stopped < a year
Passive Smoker Passive Smoker
HypertensionYesNo HypertensionYesNo
Alcohol Intake Alcohol Intake
StrokeYesNo StrokeYesNo
Never consumed Yes, drinks alcohol Never consumed Yes, drinks alcohol
Heart AttackYesNo Heart AttackYesNo
DiabetesYesNo Excessive Alcohol Intake DiabetesYesNo Excessive Alcohol Intake
In the past month, had 5 drinks in one In the past month, had 5 drinks in one
AsthmaYes No AsthmaYes No
occasion Yes No occasion Yes No
CancerYes No CancerYes No
Kidney Disease Yes No High Fat/High Salt Food Intake Kidney Disease Yes No High Fat/High Salt Food Intake
Eats processed/fast foods (e.g. instant Eats processed/fast foods (e.g. instant
Presence or absence of Diabetes Presence or absence of Diabetes
noodles, hamburgers, fries, fried chicken noodles, hamburgers, fries, fried chicken
Was patient diagnosed as having skin, etc.) and ihaw-ihaw (e.g. isaw, adidas, Was patient diagnosed as having 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
Raised BP Yes No Does at least 2 ½ hours a week of moderate- Raised BP Yes No Does at least 2 ½ hours a week of moderate-
intensity physical activity Yes No intensity physical activity Yes No
Systolic 1st reading Systolic 1st reading
Action: Action:
Diastolic 1st reading Diastolic 1st reading
Referred to health center Date Referred to health center Date
Systolic 2nd reading Systolic 2nd reading
& Time: _____________________ & Time: _____________________
Diastolic 2nd reading Given Health Information Diastolic 2nd reading Given Health Information
Average Blood Pressure Average Blood Pressure
/ Assessment done by: ___________________ / Assessment done by: ___________________

Printed Name and Signature Printed Name and Signature