Part 1.

Target Client List for Risk-Assessed Adults 20 Years Old and Above
No. Date of Family Name Complete Address SES Age Sex Risk Assessment Result Risk Screening Result
Assessment Serial Family Name, First Name, Middle Initial
1- (M or F)
Current Binge Overweight/ Hypertension Diabetes Mellitus
(mm/dd/yy) Number NHTS Smoker Alcohol Obese (11) (12)
2-Non- Drinker
NHTS
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)
 Part 2. Target Client List for Cervical Cancer Screening and Breast Mass Examination
No. Date of Family Name Age Complete Address SES Risk Type of Cervical Result of Breast Mass
Assessment Serial (Family Name, First Name, Middle Initial) Assessment Cancer Diagnosis/ Examination
(mm/dd/yy) Number Status Screening Done Screening With suspicious
breast mass
1-NHTS √ - Presence of at V - VIA N - Negative Y - Yes
2-Non- least one P - Pap Smear P - Positive N - No
NHTS Risk Factor
SC - Suspicious
X - No risk factor CA

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
 Part 3. Target Client List for Visual Acuity Screening, PPV and Influenza Part 3. Targ
Immunization for Senior Citizens (1/2)
No. Date of Family Serial OSCA ID No. Name Complete Address SES Sex Age No.
Assessment Number (Family Name, First Name, Middle Initial) (M or F) (in
(mm/dd/yy) years)

1 - NHTS
2 - Non-
NHTS

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

Part 3. Target Client List for Visual Acuity Screening, PPV and Influenza Immunization
for Senior Citizens (2/2)
Eye Complaints Visual Acuity With Eye Pinhole Vision PPV Influenza
(blurred, floaters, (Write result as Problem (for VA > 20/40) (12) Management Immunization Immunization
tearing, blind fraction) (10) (13) (Date given) (Date given)
spots, redness,
photopsia, glare) Date referred to Date referred to an Ophthalmologist
20/40 > 20/40 √ - if col 9 is √ & Improved No
√ - w/ at least Optometrist
VA is > 20/40 (put √) improve-
one
X - if col 9 is X ment
X – none of the
& VA is 20/40 (put √) If VA is 20/40 to If VA is 20/40 to If VA is 20/200 or
above
20/100 but improved 20/100 but did not worse
with pinhole improve with pinhole

(9) (11) (14) (15)