Section A:Demographics and Risk Score variables Country: ________; Participants ID No: ______________: Location (Geocode): ___
Any history of known CVD (stroke, myocardial infarction, or angina) Yes, No. If Yes, Stop.
Age___; Sex: Male, Female;
(i) Height______ Metre; (ii) Weight: ________ (Kg)
Blood pressure measurements to be taken 3 times, and at 2–3 min intervals: SBP1______; DBP1: ______ SBP2____; DBP2____ SBP3______; DBP3___
Treated for Hypertension (or on Medication for high blood pressure): Yes, No
Currently Smoking: Yes, No
Diagnose with diabetes mellitus. Yes, No. On Medication for diabetes mellitus, Yes, No
Rate Questions 7 & 8 the following from 1 and 5 (1 is less likely, and 5 is most likely.
Not at all (0); Very little risk (1); Somewhat at risk (2); moderate risk (3); not to high risk (4); High risk (5)
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9.
I am willing to go have a check-up to know the state of my heart, or check if I have hypertension. Yes, No, Undecided
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10.
In the past 6 months, have you sought attention of any medical personal or tradition practitioner or others when you were seeking or needed health care? Yes, No.
If Yes to Question 9, who among these did you visit (Please tick as appropriate) Medical doctor, Clinic, Traditional, herbalist, CHWs, CHEWs, Others: Specify Section B: Risk Score and Referral
Participant’s Risk Score: ____. If Score is ≥20%, questions Section B-D will be visible on the app
Is participant referred to community health centre (CHC)—Yes/No—Date: ___. Name of CHC
If no referral is made, please give one main reason:________________
Section C: Follow-up (at clinic
Received treatment? Yes, No; Date: ______ If ‘No’ please give one main reason:____
If ‘Yes’, what was the feedback about care received at the CHC. (0) I was not attended to at all in the PHC; (1) I attended, but I was not satisfied with the care; (2) I received good care and was satisfied. |