ID NO.

CVD/NCD ASSESSMENT FORM

CCT NCCT NON-NHTS NHTS IP
For Adults 20 years old and above
Date of Assessment Birthdate Age Risk Level: ( ) 10% ( ) 10% to < 20% ( ) 20% to 30 % ( ) ≥ 30%
Name Civil Status Sex Questionnaire to determine probable angina, hearth attack, stroke or transient ischemic
S M W M F attack, angina or heart attack ( ) Yes ( ) No
Adress Contact Number
Occupation Educational Attainment 1. Have you had any pain or discomfort or any pressure or heaviness in/your chest?
Family History Smoking (tobacco/cigarette) Nakakaramdam ka ba ng pananakit o kabigatan sa iyong dibdib? ( ) Yes ( ) No If No,
Does Patient Have 1st degree Relative ( ) Never Smoke ( ) Stopped > a year go to question 8
With: ( ) Current Smoeker ( ) Stopped < a year 2. Do you get the pain in the center of the chest or left chest or left arm? Ang sakit ba ay
Hypertension YES NO ( ) Passive Smoker nasa gitna ng dibdib, sakaliwang bahagi ng dibdib o sa kaliwang braso? ( ) Yes ( )
Stroke YES NO Alcohol Intake No. If No, go to question 8
Heart Attack YES NO ( ) Never Consumed ( ) Yes 3. Do you get it when you walk uphill or hurry? Nararamdaman mob a ito kung ikaw ay
Diabetes YES NO Excessive Alcohol Intake nagmamadali o naglalakad nang mabilis o paakyat? ( ) Yes ( ) No
Asthma YES NO In the Past mos., had 5 drinks in one occasion 4. Do you slowdown if you get the pain while walking? Tumitigil kaba sa paglalakad pag
Cancer YES NO ( ) Yes ( ) No sumasakit ang iyong dibdib? ( ) Yes ( ) No
Kidney Disease YES NO For Male Client: For Female Client: 4 or 5. Does the pain go away if you stand still or if you take a tablet under the tongue?
Obesity 5 or more standard more standard drinks Nawawala ba ang sakit kapag ikaw ay kumikilos o kapag naglagay ka ng gamut sa
______ Ht(cm) Wt (kg) + ht drinks in a row ( in 1 in a row ( in 1 sitting) ilalim ng iyong dila? ( ) Yes ( ) No
______ Wt(kg) (cm) x 10,000 sitting) ( ) Yes ( ) No 6. Does the pain go away in less than 10 minutes? Nawawala ba ang sakit sa loob ng 10
______ = BMI ( ) Yes ( ) No minuto? ( ) Yes ( ) No
High Fat/High Salt Food Intake 7. Have you ever had a severe chest pain across the front of your chest lasting for half an
Central Obesity Yes No Eats Processed/Fast food (e.g. instant noodles, hour or more? Nakaramdam ka na ba ng pananakit ng dibdib na tamagal ng kalahating
hamburgers, fries, fried chicken skin, etc.) and oras o higit pa? ( ) Yes ( ) No
ihaw – ihaw (e.g isaw,adidas,etc.) weekly ( ) If the answer to question 3 or 4 or 5 or 6 or 7 is YES, Patient may have angina or heart attack
______ Waist Circumference (cm)
Yes ( ) No and needs to see the doctor. STROKE and TIA ( ) Yes ( ) No
Raised BP ( ) Yes ( ) No Diatary Fiber Intake: Physical Inactivity: 8. Have you ever had any of the following: difficult in taking, weakness of arm and/or leg
3 servings of vegetables Does atleast 2 ½ hours a on one side of the body or numbness on one side of the body? Nakaramdam kana ba ng
Always get the average of Daily ( ) Yes ( ) No week of moderate – intensity mga sumusunod: hirap sa pagsasalita, panghihina ng braso at o ng binti o pamamanhid
two readings obtained 2-3 servings of fruits physical activity sa kalahating bahagi ng katawan? ( ) Yes ( ) No
atleast 2 minutes apart Daily ( ) Yes ( ) No ( ) 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.
VIA ( female client): BREAST EXAMINATION (female client) Note/ Remarks
Presence or absence of Diabetes 2 or more of the above symptoms are present, Note Remarks
present, perform a blood glucose test:
1. Was the patient diagnosed as having diabetes? Raise Blood Glucose ( ) Yes ( ) No DIGITAL RECTAL EXAMINATION ( male client 40 y.o and Other Remarks:
( ) Yes ( ) No ( ) Do not know ________ FBS/RBS Date Taken _________ above)
With medication w/o Medication If YES, perform URINE TEST for KETONES
2. And perform URINE TEST for KETONES Raise Blood Lipids ( ) Yes ( ) No
3. If No or Do not know , proceed to question 2 ______ Total Cholesterol Date Taken ________ Management ( ) Lifestyle Modification ( ) Medication
4. Does patient have the following symptoms Presence of Urine Ketones ( ) Yes ( ) No
Polyphagia ( ) Yes ( ) No ______ Urine Ketone Date Taken _________ Follow Up: _______________
Polydipsia ( ) Yes ( ) No Presence of Urine Protein
Polyuria ( ) Yes ( ) No ______ Urine Protein Date Taken _________ Other Notes: __________________________________________________________________________________________

Findings: _____________________________________________________________________________________________
Assessed by: _________________________