Handout - Healthy Heart, Healthy Family, A CHW Manual

Session 12 Handout Community Health Worker Activities Form

FOR INTERNAL USE ONLY (For Strategy 3)

Please complete this form after the manual is taught to record the encounters with the patient.

Participant identification (ID) number:

Name of person completing the form:

Community Health Worker identification (ID) number:

Name of person who taught the manual:

Project Location: Clinic

Which of the following activities do you do? Mark your answer with an X.

Activity Form

Activity

First Followup Encounter

3-Month Followup

6-Month Followup

12-Month Followup

Date (MM/DD/YYYY)

1. Listen to the patient's concerns. Yes, No

2. Make an appointment for the patient. Yes, No

3. Remind the patient to keep the appointment. Yes, No

4. Make transportation arrangements for patient. Yes, No

5. Serve as interpreter for the patient. Yes, No

6. Provide counseling/educational materials to patient. Yes, No

7. Go over counseling/educational materials with patient. Yes, No

8. Ask patient if he or she has any questions about the medication. Yes, No

9. Encourage patient to stay on treatment plan. Yes, No

10. Give suggestions to the patient on how to remember to take the medication. Yes, No

11. Ask the patient about difficulties in changing his or her lifestyle habits. Yes, No

12. Explain benefits of changing lifestyle habits to patient. Yes, No

13. Encourage patient to participate in support groups. Yes, No

14. Refer patient to health and community services. Yes, No

15. Conduct followup home visit. Yes, No

16. Conduct followup phone call. Yes, No

17. Write down what you discussed during the home visit or phone call. Yes, No

18. Meet with supervisor on a regular basis. Yes, No

19. File notes in patient's chart. Yes, No

20. Other:

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