Your Heart, Your Life: A Community Health Worker's Manual for the Hispanic Community

Session 12 Handout Clinical Measures and Followup Form

Download Clinical Measures and Followup Form pdf document (79k, 3 pages) handout.

FOR INTERNAL USE ONLY (For Strategy 3)

Participant identification (ID) number:

Name of person completing the form:

Promotor(a) identification (ID) number:

Project Location: Clinic

Participant Information

  1. Today's date ( MM / DD / YYYY ):
  2. Age (in years):
  3. Gender: Male, Female
  4. Do you consider yourself Latino or Hispanic? Yes, No
  5. Which race do you consider yourself to be? Alaska Native, American Indian, Asian, Black or African American, Native Hawaiian or other Pacific Islander, White
  6. Place of birth: City, State, Country
  7. Time living in the United States: Years, Months
  8. Preferred Language: English, Spanish, Both
  9. Does your family have a history of heart disease? Yes, No, Don't know
  10. Blood Cholesterol
    Question Baseline 6 Months After Baseline 12 Months After Baseline
    Date      
    Have you ever been told by a doctor or other health professional that you have high blood cholesterol? Yes, No      
    Are you on medication? Yes, No      
    Total (mg/dL)      
    LDL (mg/dL)      
    HDL (mg/dL)      
    Triglycerides (mg/dL)      
  11. Blood Pressure
    Question Baseline 6 Months After Baseline 12 Months After Baseline
    Date      
    Have you ever been told by a doctor or other health professional that you have prehypertension? Yes, No      
    Have you ever been told by a doctor or other health professional that you have high blood pressure? Yes, No      
    Are you on medication? Yes, No      
    Average of two readings: Systolic (mmHg)      
    Diastolic (mmHg)      
  12. Diabetes
    Question Baseline 6 Months After Baseline 12 Months After Baseline
    Date      
    Have you ever been told by a doctor or other health professional that you have prediabetes? Yes, No      
    Have you ever been told by a doctor or other health professional that you have high blood glucose? Yes, No      
    Are you on medication? Yes, No      
    Hb A1C (%)      
    Blood Glucose Level (fasting)      
  13. Overweight and obesity
    Question Baseline 6 Months After Baseline 12 Months After Baseline
    Date      
    Weight (pounds or kilograms)      
    Height (feet and inches or meters and centimeters)      
    Body Mass Index (BMI)      
    Waist Measure (inches or centimeters)      
  14. Medication (If the patient is on medication[s], ask the question below.)
    Question Baseline 6 Months After Baseline 12 Months After Baseline
    Date      
    Do you take your medication as prescribed by the doctor? Yes, No      
  15. If the answer to question 14 is “no,” please ask the patient: “Can you tell me why you are not taking your medication?” (Based on the patient's response, please check all the answers that apply.)
    Questions about Medications
    Question Baseline 6 Months After Baseline 12 Months After Baseline
    Date      
    a. I believe that taking medication every day is not good for me. Yes, No      
    b. I forget to take my medication. Yes, No      
    c. I did not understand what the doctor told me. Yes, No      
    d. I stopped taking the medication when I felt better. Yes, No      
    e. I feel sick when I take the medication. Yes, No      
    f. I do not have anyone to help me. Yes, No      
    g. I do not have money to buy the medication. Yes, No      
    h. Other reason (please specify):      

Back to Session 12

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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