RISK FACTOR ASSESSMENT FORM

Instructions:
This worksheet serves as a guide for identifying individuals who are at risk. This includes
your clients, family, your friends, co-workers, etc. Remember that this is only a screening
checklist. For positive findings,
more in-depth assessment may be needed.
Name of Client: ______________________________ Residence

Rural

Urban

Modifiable Risk Factors

1. Hypercholesterolemia (if laboratory results are available)
Elevated total cholesterol
YES
Elevated LDL
YES
Elevated triglycerides
YES
Low HDL
YES

NO
NO
NO
NO

2. Hypertension
BP = ____________mm Hg
Hypertensive
3. Cigarette/ tobacco smoking
Current smoker
No. of cigarettes per day
Age started smoking
No. of quit attempts
Any desire to quit
Ex-smoker
Age started smoking
Age quit
No. of cigarettes smoked/day
at the time of regular smoking
4. Alcohol drinking
Alcohol drinker
Type of alcohol
How many times
Usual amount per intake
In the past month, how many
times did you have 5 drinks in
one occasion?
In the past month, did you drive
a vehicle while intoxicated?
In the past month, did you
operate a machinery while
intoxicated?

YES
_____
_____
YES
YES
_____

NO
_____

NO
NO
_____

_____
YES
NO
___ beer ___ wine ___ distilled spirit
___/day

___/week ___/month
_____

_____
YES

NO

YES

NO

5. Physical inactivity
Type of work/ occupation
Activities other than work
(leisure, hobbies, etc.)
Means to travel to work

________________________
________________________
________________________

6. Obesity
BMI = _____Kgs/m2
Normal Below Normal Elevated
Waist Circumference = ___cms Normal Below Normal Elevated
Waist-hip rate = ______
7. Diabetes mellitus
Have you been diagnosed with
diabetes mellitus?
YES
NO
8. Inadequate dietary fiber intake
Servings of fruit per day = _____
Adequate
Inadequate
Servings of vegetable = _____
Adequate
Inadequate
9. Stress
Do you feel stressed?
YES
NO
Sources of stress
______________________

Nonmodifiable Risk Factors

Age: ____________years
Sex: Male

Female

Family history of:

Hypertension
Cardiovascular disease
Diabetes mellitus
Asthma
Cancer

Guide Questions:
1. What are the risk factors present?
2. What will you advise this client?
3. Are there recommended actions? e.g referral, treatment, etc.

YES
YES
YES
YES
YES

NO
NO
NO
NO
NO

______________________________________
Name of Interviewer/ Date Accomplished