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. 2022 Dec 24;20(1):298. doi: 10.3390/ijerph20010298
Section A:Demographics and Risk Score variables
Country: ________; Participants ID No: ______________: Location (Geocode): ___
  1. Any history of known CVD (stroke, myocardial infarction, or angina) Yes, No. If Yes, Stop.

  2. Age___; Sex: Male, Female;

  3. (i) Height______ Metre; (ii) Weight: ________ (Kg)

  4. Blood pressure measurements to be taken 3 times, and at 2–3 min intervals: SBP1______; DBP1: ______ SBP2____; DBP2____ SBP3______; DBP3___

  5. Treated for Hypertension (or on Medication for high blood pressure): Yes, No

  6. Currently Smoking: Yes, No

  7. 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.
  • 8.

    Do you think you are at risk of heart attack or any heart disease or hypertension (do not share participant’s your risk score before this question)? Scale of 0–5.


     Not at all (0); Very little risk (1); Somewhat at risk (2); moderate risk (3); not to high risk (4); High risk (5)
  • 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

  • 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
  1. Participant’s Risk Score: ____. If Score is ≥20%, questions Section B-D will be visible on the app

  2. Is participant referred to community health centre (CHC)—Yes/No—Date: ___. Name of CHC

  3. If no referral is made, please give one main reason:________________


Section C: Follow-up (at clinic
  • 4.

    Participant visited Clinic Yes, No; Date: ____________


     Received treatment? Yes, No; Date: ______ If ‘No’ please give one main reason:____
  • 5.

    Does the participant have followed-up plan for treatment at the CHC? Yes, No.


     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.