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Screening Form

Download Screening Form pdf document (33k) handout.

FOR INTERNAL USE ONLY (For Strategy 2b)

Participant identification (ID) number:

Name of person completing the form:

Promotor(a) 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.

Screening Form
Screening Information Pretest Posttest
Date (MM/DD/YYYY)    
Blood Pressure
Average of two readings:
Systolic: (top number) mmHg    
Diastolic: (bottom number) mmHg    
Overweight and Obesity Height: feet and inches or meters and centimeters    
Weight: pounds or kilograms    
Body Mass Index (BMI): BMI    
Waist measure: inches or centimeters    

Blood Cholesterol

Total: mg/dL    
LDL: mg/dL    
HDL: mg/dL    
Triglycerides: mg/dL    
Blood Glucose Hb A1C    
Blood glucose level (nonfasting)    
Blood glucose level (fasting)    

All participants with elevated levels are to be referred for further evaluation.

  • Does participant have elevated level(s)? Yes, No
    If yes, participant was referred to:
  • Did the participant go for followup care? Yes, No

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Information on this page is taken from the English print version of “Your Heart, Your Life, 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

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