Appendix 3. NCD Risk Assessment and Screening Form
NCD HIGH-RISK ASSESSMENT
ore (faclity Form)
Date of Assessment: BirthDate: Age
Name: Coal satus er
smMcwl|Mm F
Raaress, Contact Numbers:
‘Gecupation: ‘Educational Attainment:
Family History king Tobacco/ Cigarette)
Does patienthave 18 degree Neversmoked L_ Stopped> ayear
relative with: Currentsmoker L] stopped
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