Download Screening Form
FOR INTERNAL USE ONLY (For Strategy 2b)
Participant identification (ID) number:
Name of person completing the form:
Community Health Worker identification (ID) number:
Project Location (please specify): Community-based organization, Other setting:
Name of partnering organization:
Use this chart to record the screening information from each project participant.
All participants with elevated levels are to be referred for further evaluation.
Information on this page is taken from the English print version of “Healthy Heart, Healthy Family: A Community Health Worker's Manual.” U.S. Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute, NIH Publication No. 08-3674, Originally Printed 1999, Revised May 2008.
Last Updated March 2012