Hypertension

Age:
Gender
Height
Weight:
1st reading BP: ______/_______mmHg Date:
2nd reading BP: ______/_______mmHg Date:
:

1. Has any of you relatives been diagnosed with hypertension?

_YES
_NO
2. Have you ever been diagnosed with Hypertension by the doctor?
_NO
_YES
3. Do you eat many foods containing high salt content?
_YES
_NO
4. Are you taking any anti-hypertensive drugs currently?
_NO
_YES
5. Do you currently smoke cigarettes or any other tobacco products on a daily basis?
_No
_Yes
6. Do you drink alcohol? If yes, what is your rate of consumption?
_NO
_YES
_______can/bottle per day/week/ month OR OCCASIONALLY
Bronchial Asthma
Age:
Gender:
Heigh:
Weight:
RR:
BP: _________/_______mmHg

1. presence of one or combination of following

_dyspnea
_cough
_wheEzing
_chest discomfort
2. Temporal waxing and waning and/or nocturnal occurrence of symptoms
_NO
_YES
3. History of any of the following:
_symptoms triggered by exogenous factors
_family history of allergy or asthma
_a personal history of asthma, allergic rhinitis or atopy
_an improvement of symptoms with bronchodilator use
4. Do you currently smoke cigarettes or any other tobacco products on a daily basis?
_No
_Yes
5. What is your daily diet?
_

6. Do you intake alcohol? If yes, what is your rate of consumption?

_NO
_YES
Diabetes Mellitus

1. Your age group

_Under 35 years
_35-44 years
_45-54 years
_55-64 years
_65 years or over

2. Your gender
_Female
_Male

3. Height ______
Weight ______

4. Have either of your parents, or any of your brothers or sisters been diagnosed with
diabetes (type 1 or type 2)?
_No
_Yes

5.Have you ever been found to have high blood glucose (sugar) (for example, in a health
examination, during an illness, or during pregnancy)?
_No
_Yes

6.Are you currently taking medication for high blood pressure or diabetes (if yes what
medication)?
_No
_Yes

7. Do you currently smoke cigarettes or any other tobacco products on a daily basis?
_No
_Yes

8. Do you experience increased frequency and amount of urination?

_No
_Yes

9. How often do you eat vegetables or fruit?

_Every day
_Not every day

10. On average, would you say you do at least 2.5 hours of physical activity per week (for
example, 30 minutes a day on 5 or more days a week)?
_Yes
_No

11. Do you experience thirst very frequently?

_No
_Yes

12. Have you experienced unexplained weight loss recently?

_No
_Yes
PNEUMONIA CHECKLIST
NAME: ____________________
ADDRESS: _____________________________________
(1) REMEMBER
• Respiratory rate ≥25 bpm is highly
specific and sensitive for
PNEUMONIA
• Respiratory rate ≥40 bpm may be
an indication for transfer to hospital
• If resident has problems
swallowing, consider aspiration
pneumonia.
(2) REMEMBER
• If cough and fever are present,
consider viral respiratory tract
infection, especially influenza during
November to April. Refer to Public
Health Guidelines for case definitions.
• If chest pain and elevated
temperature are absent, consider
another diagnosis (for example CHF).