Part 1.

Target Client List for Risk-Assessed Adults 20 Years Old and Above
No. Date of Name Complete Address SES Age Sex Risk Assessment Result Risk Screening Result
Assessment Family Name, First Name, Middle Initial
1-NHTS (M or F)
Current Binge Overweight/ Hypertension Diabetes Mellitus
(mm/dd/yy) 2-Non-NHTS Smoker Alcohol Obese (11) (12)
Drinker
Y - Yes Y - Yes 1 - overweight
23.0-24.9 kg/m2
Date of Ave. 2 BP
readings
Date of + positive
FBG ≥126mg/dL or
N - No N - No 2 - obese Screening +:≥ Screening RBS≥ 200mg/dL
≥ 25 kg/m2 (mm/dd/yy) 140/90mmHg (mm/dd/yy) - negative
-:< FBG <126mg/dL or
140/90mmHg RBS< 200mg/dL

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 NCD MEDS FOLLOW UP Part 3. Target Client List for Visual Acuity
Screening
Eye
Complain
Visual Acuityand
(Write
With PPV
Eye
Problem
Immunization
Pinhole Vision
20/40result as >fraction)
√ 20/40
for Senior
Management PPV
Immuniza
- if col 9 is (for VA > 20/40)No
Improved (12) Date
(13)
Date referred to an
MONTHLY FOLLOW UP ts (10)
√& (put √) improve- referred to Ophthalmologist tion
(blurred, ment Optometrist (Date given)
VA is >
floaters, 20/40 (put √)
tearing, blind
spots,
X - if col 9 is If VA is 20/40 If VA is 20/40 If VA is
X to 20/100 but to 20/100 but 20/200 or
redness,
& VA is improved did not worse
photopsia,
20/40 with pinhole improve with
JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC glare) pinhole
√ - w/ at least
(9)
one (11) (14)
X – none of
the above
 Part 2. Target Client List for Cervical Cancer Screening and Breast Mass Examinatio
No. Date of Family Serial Name Age Complete Address SES Risk Type of Cervical Result of
Assessment Number (Family Name, First Name, Middle Initial) Assessment Cancer Diagnosis/
(mm/dd/yy) Status Screening Done Screening
1-NHTS √ - Presence of at V - VIA N - Negative
2-Non-NHTS least one Risk P - Pap Smear P - Positive
Factor
SC - Suspicious CA
X - No risk factor

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on
Breast Mass
Examination
With suspicious
breast mass
Y - Yes
N - No

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 Part 3. Target Client List for Visual Acuity Screening Part 3. Target Client List for Visual Acuity Scr
and PPV Immunization for Senior Citizens (Part 1 of 2) PPV Immunization for Senior Citizens (P
No. Date of Assessment Family Serial OSCA ID No. Name Complete Address SES Sex Age Eye Complaints Visual Acuity With Eye Pinhole Vision Management
(mm/dd/yy) Number (Family Name, First name, Middle Initial) (M or F) (in years) (blurred, floaters, (Write result as fraction) (10) Problem (for VA > 20/40) (12) (13)
tearing, blind spots,
1 - NHTS redness, photopsia, 20/40 > 20/40 √ - if col 9 is √ & Improved No Date referred to Date referred to an O
2 - Non-NHTS glare) VA is > 20/40 (put √) improve- Optometrist
ment
√ - w/ at least one X - if col 9 is X If VA is 20/40 to If VA is 20/40 to
& VA is 20/40 (put √)
20/100 but 20/100 but did not
X – none of the above improved with improve with
pinhole pinhole

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reening and
(Part 2 of 2)

PPV
Immunization
n Ophthalmologist (Date given)

If VA is 20/200 or
worse

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