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    Facility Risk Assessment Form v.2

    Uploaded by

    Errol Llanes
    The document appears to be a questionnaire to assess risk factors for cardiovascular diseases like angina, heart attack, stroke, and transient ischemic attack. It asks questions about symptoms like chest pain and discomfort, as well as lifestyle factors like smoking, alcohol consumption, diet, physical activity, family history and medical history. Based on the answers, it determines the person's risk level for these conditions and whether they need to see a doctor or make lifestyle changes.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Facility Risk Assessment Form v.2

    Uploaded by

    Errol Llanes
    336 views1 page
    The document appears to be a questionnaire to assess risk factors for cardiovascular diseases like angina, heart attack, stroke, and transient ischemic attack. It asks questions about symptoms like chest pain and discomfort, as well as lifestyle factors like smoking, alcohol consumption, diet, physical activity, family history and medical history. Based on the answers, it determines the person's risk level for these conditions and whether they need to see a doctor or make lifestyle changes.

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    Facility-Risk-Assessment-Form-v.2

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    The document appears to be a questionnaire to assess risk factors for cardiovascular diseases like angina, heart attack, stroke, and transient ischemic attack. It asks questions about symptoms like chest pain and discomfort, as well as lifestyle factors like smoking, alcohol consumption, diet, physical activity, family history and medical history. Based on the answers, it determines the person's risk level for these conditions and whether they need to see a doctor or make lifestyle changes.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    336 views1 page

    Facility Risk Assessment Form v.2

    Uploaded by

    Errol Llanes
    The document appears to be a questionnaire to assess risk factors for cardiovascular diseases like angina, heart attack, stroke, and transient ischemic attack. It asks questions about symptoms like chest pain and discomfort, as well as lifestyle factors like smoking, alcohol consumption, diet, physical activity, family history and medical history. Based on the answers, it determines the person's risk level for these conditions and whether they need to see a doctor or make lifestyle changes.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Questionnaire to Determine Probable Angina, Heart Attack, Stroke or Transient Ischemic Attack Angina or Heart AttackYesNo

    1.Have you had any pain or discomfort or any pressure or heaviness in your chest? Nakakaramdam ka ba ng pananakit
    CVD/NCD RISK ASSESSMENT FORM o kabigatan sa iyong dibdib?
    ID No. For adults 20 years old and above

    Date of Assessment: Birth Date: Age:  Yes/Oo  No/Hindi If NO, go to Question 8.


    2. Do you get the pain in the center of the chest or left chest or left arm? Ang sakit ba ay nasa gitna ng dibdib, sa
    kaliwang bahagi ng dibdib o sa kaliwang braso?
    Name: Civil Status: Sex:  Yes/Oo  No/Hindi If NO, go to Question 8.
    S M W M F 3. Do you get it when you walk uphill or hurry? Nararamdaman mo ba ito kung ikaw ay nagmamadali o
    Address: Contact Numbers: naglalakad nang mabilis o paakyat?  Yes/Oo  No/Hindi
    4. Do you slowdown if you get the pain while walking? Tumitigil ka ba sa paglalakad kapag sumakit ang iyong dibdib?
     Yes/Oo  No/Hindi
    Occupation: Educational Attainment: 5. Does the pain go away if you stand still or if you take a tablet under the tongue? Nawawala ba ang sakit kapag
    ikaw ay di kumilos o kapag naglagay ka ng gamot sa ilalim ng iyong dila?  Yes/Oo No/Hindi
    6. Does the pain go away in less than 10 minutes? Nawawala ba ang sakit sa loob ng 10 minuto?
    Family History Smoking (Tobacco/Cigarette)
     Yes/Oo  No/Hindi
    Does patient have 1st degree Never smoked Stopped > a year
    7. Have you ever had a severe chest pain across the front of your chest lasting for half an hour or more? Nakaramdam
    relative with: Current smoker Stopped < a year ka na ba ng pananakit ng dibdib na tumagal ng kalahating oras o higit pa?  Yes/Oo  No/Hindi
    Passive Smoker
    Hypertension Yes No IF the answer to Questions 3 or 4 or 5 or 6 or 7 is YES, patient may have angina or heart attack and needs to see the doctor.
    Alcohol Intake
    Stroke Yes No Stroke and TIA Yes No
    Never consumed Yes
    Heart Attack Yes No 8. Have you ever had any of the following: difficulty in talking, weakness of arm and/or leg on one side of the body or
    Diabetes Yes No Excessive Alcohol Intake numbness on one side of the body? Nakaramdam ka na ba ng mga sumusunod: hirap sa pagsasalita, panghihina ng
    In the past month, had 5 drinks in one braso at/o ng binti o pamamanhid sa kalahating bahagi ng katawan?  Yes/Oo  No/Hindi
    Asthma Yes No
    occasion Yes No
    Cancer Yes No If the answer to Question 8 is YES, the patient may have had a TIA or stroke and needs to see the doctor.
    Kidney Disease Yes No High Fat/High Salt Food Intake
    Eats processed/fast foods (e.g. instant Presence or absence of Diabetes Raised Blood Glucose Yes No
    Obesity Yes No
    noodles, hamburgers, fries, fried chicken 1. Was patient diagnosed as having diabetes? FBS / RBS Date taken
    Ht (cm) BMI skin, etc.) and ihaw-ihaw (e.g. isaw, adidas, Yes No Do not know
    etc.) weekly Yes No Raised Blood Lipids Yes No
    with medications w/o medications
    Wt (kg)
    Dietary Fiber Intake: Total Cholesterol Date taken
    Wt (kg) ÷ Ht (cm) ÷ Ht (cm) x 10,000 = BMI 3 servings of vegetables daily Yes No If No or Do not know, proceed to question 2

    Central Adiposity Yes No 2-3 servings of fruits daily Yes No Presence of Urine Protein Yes No
    2. Does patient have the following symptoms?
    Polyphagia Yes No Urine Protein Date taken
    Waist circumference (cm) Physical Activity Polydipsia Yes No
    Does at least 2 ½ hours a week of moderate- Polyuria Yes No Presence of Urine Ketones (for newly diagnosed
    Raised BP Yes No
    intensity physical activity Yes No DM) Yes No N/A
    Systolic If two or more of the a bo e symptoms are present,
    v
    perform a blood glucose test. Urine Ketones Date taken
    Diastolic Assessed by:
    Management: Lifestyle Modification Medications Date of Follow-up:
    Always get the average of two readings
    obtained at least 2 minutes apart.
    Name and Signature

    Risk Level : 5% 5%-<10% 10% to <20% 20% -<30% ≥30% Findings:

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