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Your Heart, Your Life: A Community Health Worker's Manual for the Hispanic Community
Session 12 Handout Screening Form
Download Screening Form 
(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 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
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
