Part 1.

Target Client List for Risk-Assessed Adults 20 Years Old and Above
No. Date of Family Serial Name Complete Address SES Age Sex Risk Assessment Result Risk Screening Result
Assessment Number Family Name, First Name, Middle Initial (M or F)
1-NHTS Current Binge Overweight/ Hypertension Diabetes Mellitus
(mm/dd/yy) 2-Non-NHTS Smoker Alcohol Obese (11) (12)
Drinker
Y - Yes Y - Yes 1 - overweight Date of Ave. 2 BP readings Date of + positive
N - No N - No 23.0-24.9 kg/m2 Screening + : ≥ 140/90mmHg Screening FBG ≥126mg/dL or
2 - obese (mm/dd/yy) - : < 140/90mmHg (mm/dd/yy) RBS≥ 200mg/dL
≥ 25 kg/m2 - negative
FBG <126mg/dL or
RBS< 200mg/dL
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

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 Part 2. Target Client List for Cervical Cancer Screening and Breast M
No. Date of Family Serial Name Age Complete Address SES Risk
Assessment Number (Family Name, First Name, Middle Initial) Assessment
(mm/dd/yy) Status
1-NHTS √ - Presence of at
2-Non-NHTS least one Risk
Factor
X - No risk factor

(1) (2) (3) (4) (5) (6) (7)

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st Mass Examination
Type of Cervical Result of Breast Mass
Cancer Diagnosis/ Examination
Screening Done Screening With suspicious
breast mass
V - VIA N - Negative Y - Yes
P - Pap Smear P - Positive N - No
SC - Suspicious CA

(8) (9) (10)

 Part 3. Target Client List for Visual Acuity Screening, PPV and Part 3. Target Client List
Influenza Immunization for Senior Citizens (Part 1 of 2) Influenza Immuniz
No. Date of Assessment Family Serial OSCA ID No. Name Complete Address SES Sex Age Eye Complaints Visual Acuity With Eye
(mm/dd/yy) Number (Family Name, First name, Middle Initial) (M or F) (in years) (blurred, floaters, (Write result as fraction) (10) Problem
tearing, blind spots,
1 - NHTS redness, photopsia, 20/40 > 20/40 √ - if col 9 is √ &
2 - Non-NHTS glare) VA is > 20/40
√ - w/ at least one X - if col 9 is X
& VA is 20/40
X – none of the above

(1) (2) (3) (4) (5) (6) (7) (8) (9) (11)

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st for Visual Acuity Screening, PPV and
nization for Senior Citizens (Part 2 of 2)
Pinhole Vision Management PPV Influenza
(for VA > 20/40) (12) (13) Immunization Immunization
Improved No Date referred to Date referred to an Ophthalmologist (Date given) (Date given)
(put √) improve- Optometrist
ment
If VA is 20/40 to If VA is 20/40 to If VA is 20/200 or
(put √) 20/100 but 20/100 but did not worse
improved with improve with
pinhole pinhole

(14) (15)