PHILPEN RISK ASSESSMENT FORM (REVISED 2022)

Adults ≥20 years old

Name of Health Facility: Date of Assessment:

I. PATIENT’S INFORMATION

Patient Name: (SURNAME, Given Name, Middle Name) Age Sex Birthdate:

PHIC No.: Civil Status: Religion Contact No.

Patient's Address:
Persons with Disability ID Card No., if applicable: Employment Status: [ ] Employed [ ] Unemployed [ ] Self-employed
[ ] IP [ ] Non-IP Ethnicity:

II. ASSESS FOR RED FLAGS

2.1 Chest Pain [ ] Yes [ ] No

2.2 Difficulty of Breathing [ ] Yes [ ] No
2.3 Loss of Consciousness [ ] Yes [ ] No
2.4 Slurred Speech [ ] Yes [ ] No
2.5 Facial Asymmetry [ ] Yes [ ] No If YES to ANY, REFER IMMEDIATELY to a Physician for
2.6 Weakness/ Numbness on arm of left on one side [ ] Yes [ ] No further management and/or referral to the next level of care
of the body
If ALL answers are NO, proceed to Part III.
2.7 Disoriented as to time, place and person [ ] Yes [ ] No
2.8 Chest Retractions [ ] Yes [ ] No
2.9 Seizure or Convulsion [ ] Yes [ ] No
2.10 Act of self-harm or suicide [ ] Yes [ ] No
2.11 Agitated and/or aggressive behavior [ ] Yes [ ] No
2.12 Eye Injury/ Foreign Body on the eye [ ] Yes [ ] No
2.13 Severe Injuries [ ] Yes [ ] No
III. PAST MEDICAL HISTORY

3.1 Hypertension [ ] Yes [ ] No

3.2 Heart Diseases [ ] Yes [ ] No
3.3 Diabetes [ ] Yes [ ] No
3.4 Cancer [ ] Yes [ ] No
3.5 COPD [ ] Yes [ ] No
3.6 Asthma [ ] Yes [ ] No
3.7 Allergies [ ] Yes [ ] No
3.8 Mental, Neurological, and Substance-Abuse [ ] Yes [ ] No
Disorders
3.9 Vision Problems [ ] Yes [ ] No
3.10 Previous Surgical History [ ] Yes [ ] No
3.11 Thyroid Disorders [ ] Yes [ ] No
3.12 Kidney Disorders [ ] Yes [ ] No
IV. FAMILY HISTORY

4.1 Hypertension [ ] Yes [ ] No

4.2 Stroke [ ] Yes [ ] No
4.3 Heart Disease (changed from “Cardiovascular”) [ ] Yes [ ] No
4.4 Diabetes Mellitus [ ] Yes [ ] No
4.5 Asthma [ ] Yes [ ] No
4.6 Cancer [ ] Yes [ ] No
4.7 Kidney Disease [ ] Yes [ ] No
4.8 1st degree relative with premature coronary [ ] Yes [ ] No
disease or vascular disease (includes “Heart Attack”)
4.9 Family members having TB in the last 5 years. [ ] Yes [ ] No
4.10 Mental, Neurological and Substance Abuse Disorder. [ ] Yes [ ] No
4.11 COPD [ ] Yes [ ] No

V. NCD RISK FACTORS

5.1 Tobacco Use [ ] Q1 Never Used (proceed to Q2) If YES to Q2-Q4, follow the tobacco cessation protocol (5As)
[ ] Q2 Exposure to secondhand smoke and use Form 1. Tobacco Cessation Referral Protocol, if
[ ] Q3 Former tobacco user (stopped smoking >1 year) needed.
[ ] Q4 Current tobacco user (currently smoking or stopped smoking
<1year)

*remove option: number of packs used in smoking*

5.2 Alcohol Intake Q1. [ ] Never Consumed [ ] Yes, drinks alcohol If NO, congratulate the patient. The patient is at a lower risk
of drinking alcohol.
If YES, proceed using AUDIT SCREENING TOOL (Form 2)
to assess alcohol consumption and alcohol problems.

Q2. Do you drink 5 or more standard drinks for men, and 4 or more for If YES, provide brief advice and/or extended brief advice.
women (in one sitting/occasion) in the past year ? [ ] Yes [ ] No The patient is on the higher risk category level of drinking or
in harmful use of alcohol.

5.3 Physical Activity Does the patient do at least 2.5 hours a week of moderate-intensity If NO or patient does not reach the recommended hours/week
physical activity? off moderate-intensity physical activity, give lifestyle
[ ] Yes [ ] No modification advice following Annex 1. Healthy Lifestyle
Module.

5.4 Nutrition and Q1 Does the patient eat high fat, high salt food (processed/ fast food If YES to the question, give lifestyle modification advice
Dietary Assessment such as instant noodles, burgers, fries, dried fish), "ihaw-ihaw/fried (e.g. following Annex 2. Nutrition Practice Guidelines for Health
isaw, barbecue, liver, chicken skin) and high sugar food and drinks (e.g. Professionals in the Primary Care Screening
chocolates, cakes, pastries, softdrinks) weekly? [ ] Yes [ ] No

5.5 Weight (kg) 5.6 Height (cm)

5.7 Body Mass Index (wt.[kgs]/ht.[cm]/ht.[cm] x 10,000): 5.8 Waist Circumference (cm): F <80cm M<90

5.9 Blood Pressure (mmHg):

VI. RISK SCREENING

6.1 Hypertension/ Blood Sugar (write NA if FBS Result Date Taken:

Diabetes/ not applicable) RBS Result
Hypercholesterolemia/
Renal Diseases CHECK if DM clinical symptoms are present:
[ ] Polyphagia [ ] Polydipsia [ ] Polyuria

Lipid Profile Total Cholesterol : Date Taken:

HDL:
LDL:
VLDL:
Triglyceride:
Urinalysis/ Urine Dipstick Protein: Date Taken:
Test Ketones: Date Taken:

6.2 Chronic Respiratory CHECK all applicable: If YES to any of the symptoms, obtain peak expiratory flow rate
Diseases (Asthma and (PEFR). Give inhaled salbutamol, then repeat after 15 minutes.
COPD) [ ] Breathlessness (or a "need for air")
[ ] Chronic cough Result:
[ ] Sputum (mucous) production [ ] >20% change from baseline (consider Probable Asthma)
[ ] Chest tightness* [ ] <20% change from baseline (consider Probable COPD)
[ ] Wheezing*
* These symptoms may be episodic or seasonal, vary over time
and intensity and are worse during night and early morning

VII. MANAGEMENT

Lifestyle Modification [ ] Yes

[ ] No

Medications:
a. Anti-Hypertensives [ ] Yes [ ] No
b. Oral Hypoglycemic Agents/Insulin [ ] Yes [ ] No

Date of Follow-up:

Remarks: