Questionnaire to Determine Probable Angina, Heart Attack, Stroke or Transient Ischemic Attack

NCD HIGH- RISK ASSESSMENT

ID No. Angina or Heart Attack Yes No
( Community Case Finding Form) 1 Have you had any pain or discomfort or any preassure or heaviness in your chest? Nkakaramdam ka ba ng pananakit
o kabigatan sa iyong dibdib?
Date of Assessment: Birth Date: Age: Yes/Oo No/ Hindi
2 Do you get the pain in the center of the chest or left chest or left arm? Ang sakit ba ay nasa gitna ng dibdib, sa
Name: Civil Status: Sex: kaliwang bahagi ng dibdib o sa kaliwang braso?
S M D W M F Yes/Oo No/ Hindi
Address: Contact Numbers: 3 Do you get it when you walk uphill or in a hurry? Nararamdaman mo ba ito kung ikaw ay nagmamadali o naglalakad
nang mabilis o paakyat?
Yes/Oo No/ Hindi
Occupation: Educational Attainment: 4 Do you slowdown if you get the pain while walking? Tumitigil ka ba sa paglalakad kapag sumakit ang iyong dibdib?
Yes/Oo No/ Hindi
5 Does the pain go away if you stand still or if you take a tablet under the tongue? Nawawala ba ang sakit kapag ikaw
Smoking (Tobacco/ Cigarette)
ay di kumilos o kapag naglalagay ka ng gamot sa ilalim ng iyong dila?
Family History Yes/Oo No/ Hindi
Does patient have 1st degree Never smoked Stopped >a year 6 Does the pain go away in less than 10 minutes? Nawawala ba ang sakit sa loon ng 10 minuto?
relative with: Current smoker Stopped <a year Yes/Oo No/ Hindi
Passive smoker 7 Have you ever had a severe chest pain across the front of your chest lasting for half an hour or more? Nakakaramdam
Hypertension Yes No Alcohol intake ka na na ng pananakit ng dibdib na tumagal ng kalahating oras o higit pa?
Stroke Yes No Never consumed Yes, drinks alcohol Yes/Oo No/ Hindi
Heart Attack Yes No If the answer to Questions 3 or 4 or 5 or 6 or 7 is YES, patient may have Angina or Heart Attack and needs to see
Diabetes Yes No Excessive Alcohol Intake the doctor.
Asthma Yes No In the past month, had 5 drinks in one occasion. Stroke and TIA
Cancel Yes No Yes No 8 Have you ever had any of the following: diffi culty in talking, weakness of arm and/or leg on one side of the body or
numbness on one side of the body? Nkakaramdam ka na ba ng mga sumusunod: hirap sa pagsasalita, panghihina
Kidney Disease Yes No High Fat/High Salt Food Intake
ng braso at/o ng binti o pamamanhid sa kalahating bahagi ng katawan? Yes No
Eats proccessed/ fast foods (e.g. instant
Presence or absence of Diabetes noodles, hamburgers, fries, fried chicken skin, If the answer to Question 8 is Yes, the patient may have has a TIA or stroke and needs to see the doctor.
Was patient diagnosed as etc.) and ihaw ihaw (e.g. isaw, adidas, etc.) Presence or absence of Diabetes Raised Blood Glucose Yes No
having diabetes? weekly Yes No 1. Was the patient diagnosed as having diabetes? FBS / RBS Date
Datetaken:
taken___________
: _______
Yes No Do not know Dietary Fiber Intake: Yes No If YES, perform Urine Test for Ketones
Central Adiposity 3 servings of vegetables daily Yes No with medications without medications
Yes No 2-3 servings of fruits daily Yes No and perform Urine Test for Ketones. Raised Blood Lipids
Waist circumference (cm) Physical Activity If No or Do not Know, proceed to question 2 Total Cholesterol Date taken: ________
Does at least 2 1/2 hours a week of 2. Does patient have the following symptoms?
Raised BP moderate intensity physical activity Polyphagia Yes No Presence of Urine Ketones
Yes No Polydipsia Yes No Urine Ketone Date taken:___________
Polyuria Yes No
Systolic 1st reading Action:
Presence of Urine Protein
Diastolic 1st reading Referred to health center
If two or more of the above symptoms are present, Urine Protein Date taken: __________
Systolic 2nd reading Date & Time: ________________
perform a blood glucose test.
Diastolic 2nd reading Given Health Information
Management: Lifestyle Modification Medications Follow-up: _____________
Average Blood Preassure Assessment done by: ___________________ __________________________________________________________________________________________________
Printed Name & Signature __________________________________________________________________________________________________
__________________________________________________________________________________________________
Risk Level: <10% 10% to <20% 20% to <30% >30%
Findings: __________________________________________________________________