ID No.

CVD/NCD RISK ASSESSMENT FORM Questionnaire to Determine Probable Angina, Heart Attack, Stroke or Transient Ischemic Attack
Angina or Heart Attack Yes No
For adults 20 years old and above
1. Have you had any pain or discomfort or any pressure or heaviness in your chest? Nakakaramdam ka ba ng pananakit o
Date of Assessment: Birth Date: Age: kabigatan sa iyong dibdib?
 Yes/Oo  No/Hindi If NO, go to Question 8.
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 kaliwang
Name: Civil Status: Sex: bahagi ng dibdib o sa kaliwang braso?
S M W M F  Yes/Oo  No/Hindi If NO, go to Question 8.
3. Do you get it when you walk uphill or hurry? Nararamdaman mo ba ito kung ikaw ay nagmamadali o naglalakad nang
Address: Contact Numbers: mabilis o paakyat?  Yes/Oo  No/Hindi
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
Family History Educational
Smoking Attainment:
(Tobacco/Cigarette) 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 ay
Does patient have 1st degree Never smoked Stopped > a year di kumilos o kapag naglagay ka ng gamot sa ilalim ng iyong dila?  Yes/Oo  No/Hindi
relative with: Current smoker Stopped < a year 6. Does the pain go away in less than 10 minutes? Nawawala ba ang sakit sa loob ng 10 minuto? 
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? Nakaramdam ka
Hypertension Yes No
na ba ng pananakit ng dibdib na tumagal ng kalahating oras o higit pa?  Yes/Oo  No/Hindi
Stroke Yes No
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 the doctor.
Diabetes Yes No Alcohol Intake
Stroke and TIA Yes No
Never consumed Yes
Asthma Yes No 8. Have you ever had any of the following: difficulty in talking, weakness of arm and/or leg on one side of the body or
Cancer Yes No Excessive Alcohol Intake numbness on one side of the body? Nakaramdam ka na ba ng mga sumusunod: hirap sa pagsasalita, panghihina ng
In the past month, had 5 drinks in one braso at/o ng binti o pamamanhid sa kalahating bahagi ng katawan?  Yes/Oo  No/Hindi
Kidney Disease Yes No
occasion Yes No
IF the answer to Question 8 is YES, the patient may have had a TIA or stroke and needs to see the doctor.
High Fat/High Salt Food Intake
Presence or absence of Diabetes
Eats processed/fast foods (e.g. instant
Obesity Yes No 1. Was patient diagnosed as having diabetes?
noodles, hamburgers, fries, fried chicken Raised Blood Glucose Yes No
Ht (cm) BMI Yes No Do not know
skin, etc.) and ihaw-ihaw (e.g. isaw, adidas,
with medications w/o medications FBS / RBS Date taken___________
Wt (kg) etc.) weekly Yes No
and perform Urine Test for Ketones. If YES, perform Urine Test for Ketones

Wt (kg) ÷ Ht (cm) ÷ Ht (cm) x 10,000 = BMI Dietary Fiber Intake: If No or Do not know, proceed to question 2 Raised Blood Lipids Yes
3 servings of vegetables daily Yes No 2. Does patient have the following symptoms? No
Central Adiposity Yes No Polyphagia Yes No Total Cholesterol Date taken___________
2-3 servings of fruits daily Yes No Presence of Urine Ketones Yes No
Polydipsia Yes No
Urine Ketone Date taken________
Waist circumference (cm) Polyuria Yes No
Physical Activity
Does at least 2 ½ hours a week of moderate- If two or more of the above symptoms are present, Presence of Urine Protein Yes No
Raised BP Yes No intensity physical activity Yes No perform a blood glucose test.
Systolic Urine Protein Date taken________
Assessed by:
Diastolic Management: Lifestyle Modification Medications Follow-up: _________________
___________________________________
_________________________________________________________________________________________
Always get the average of two readings Name and Signature
___________________________________ _________________________________________________________________________________________
Obtained at least 2 minutes apart.
Name and Signature _________________________________________________________________________________________

Risk Level: <10% 10% to <20% 20% to <30% ≥30% Findings: ________________________________________________________________________________________