ID NO.

PRESENCEOR ABSENCE OF Raised Blood Glucose __Y __N

DIABETES ___________ FBS/RBS
___________Date
DATE OF ASSESSMENT
SMOKING BIRTHDATE AGE Was the patient diagnosed as
having diabetes?___Yes __No Raised blood Lipids ___Y ___N
NAME __________Total Cholesterol
If Yes: __with medications
___without medications __________Date
CIVIL STATUS SEX ADDRESS If no or do not know, Does
the patient have the ff sx:
S M C W M F Polyphagia ____Yes ___No Presence of Urine Ketoones
OCCUPATION EDUCATIONAL ATTAINMENT Polydipsia ____Yes ___No ___Yes___No ________Date taken
Polyuria ____Yes ___No
If 2 or more of the above Presence of Urine Proteins
FAMILY HISTORY SMOKING symptoms are present, ___Yes __No ________Date taken
Does the patient have a 1st __Never smoked perform a blood glucose test.
degree relative with: __Current Smoker
__Passive smoker
HPN Yes No __Stopped > a year
STROK Yes No __Stopped < a year Questionnaire to determine Probable Angina, Heart Attack, CVA/TIA
HEART ATTACK Yes No
ALCOHOL INTAKE Angina / Heart Attack ____Yes ___No
DM Yes No
ASTHMA Yes No __Never consumed
__Drinks alcohol 1. Have you had any pain or discomfort or any pressure or heaviness
CANCER Yes No
KIDNEY DSE Yes No in your chest? ____Yes ____ No (If no, proceed to No. 8)
Excessive Alcohol 2. Do you get the pain in the center of your chest or left arm?
OBESITY __Yes __No Intake ___Yes ___No (If NO, go to question no. 8)
In the past month, 3. Do you get it when you walk uphill or hurry ? _____Yes _____No
BMI ____ HT ____ WT____ had 5 drinks in one
4. Do you slow down if you get the pain while walking ?
occasion
__Yes __No ____Yes _____No
WAIST
CIRCUMFERENCE:_____CM 5. Does the pain go away if you stand still or if you take a tablet
HIGH FAT/SALT under the tongue? ______Yes _____No
INTAKE
RAISED BP: ___YES___NO 6. Does the pain go away in less than 10 minutes ? ____Yes ___No
_____1ST SYSTOLIC READING Eats processed 7. Have you ever had severe chest pain across the front of your chest
_____1ST DIASTOLIC READING foods/fast foods
lasting for half an hour or more? _____Yes ____No
_____2ND SYSTOLIC READING and ihaw-ihaw
_____2ND DIASTOLIC READING weekly 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 the doctor.
____/____ AVERAGE BP ____Yes ____No

DIETARY FIBER INTAKE STROKE/ TIA ____Yes ____No

3 servings of vegetables daily ____Yes ____No
8. Have you ever had any of the following:
2-3 servings of fruit daily ____Yes ____No
a. Difficulty of talking _____Yes _____No
PHYSICAL ACTIVITY b. Weakness of arms and/or legs or numbness on one
Does at least 2 ½ hours a week of moderate-intensity
skjc side of the body ______Yes ______No
physical activity _____Yes _____No
If the answer to question no. 8 is YES, the patient may have had a
ASSESSED BY:
TIA or stroke and needs to see the doctor.

Name and Signature