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

Session 12 Handout 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

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




Skip footer links and go to content
Twitter icon Twitter External link Disclaimer         Facebook icon Facebook image of external link icon         YouTube icon YouTube image of external link icon