Personal tools
Navigation
 

Personal Health Risk Assessment-Screening Form

This form should assist physicians when discussing health promotion and disease prevention with their patients. The highlighted links open web-based resources for your reference. Although it is BC-centric, it can be easily modified for other jurisdictions. This was a collaborative effort between Herb Chang, Gunther Klein, and John Yap.

HTML icon PersonalHealthRiskAssessmentFormHerb.html — HTML, 11 kB (11845 bytes)

File contents

<html>
<head>
<title>Personal Risk Assessment Screening</title>

<script language="JavaScript1.2">
<!--

/***********************************************
* Auto Maximize Window Script- u00A9 Dynamic Drive (www.dynamicdrive.com)
* This notice must stay intact for use
* Visit http://www.dynamicdrive.com/ for this script and 100's more.
***********************************************/

top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){
top.window.outerHeight = screen.availHeight;
top.window.outerWidth = 900;
}
}
//-->
</script>


<style type="text/css" media="print">
 .DoNotPrint {
	 display: none;
 }
 .noborder {
	 border : 0px;
	 background: transparent;
	 scrollbar-3dlight-color: transparent;
	 scrollbar-3dlight-color: transparent;
	 scrollbar-arrow-color: transparent;
	 scrollbar-base-color: transparent;
	 scrollbar-darkshadow-color: transparent;
	 scrollbar-face-color: transparent;
	 scrollbar-highlight-color: transparent;
	 scrollbar-shadow-color: transparent;
	 scrollbar-track-color: transparent;
	 background: transparent;
	 overflow: hidden;
 }
 </style>


<!-- scripts to confirm closing of window if it hadn't been saved yet -->
<script language="javascript">
//keypress events trigger dirty flag
var needToConfirm = false;
document.onkeyup=setDirtyFlag;
function setDirtyFlag(){
		needToConfirm = true;
}
function releaseDirtyFlag(){
		needToConfirm = false; //Call this function if doesn't requires an alert.
//this could be called when save button is clicked
}
window.onbeforeunload = confirmExit;
function confirmExit(){
	 if (needToConfirm){
		 return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
	 }
}
</script>

</head>

<body>

<form method="post" action="" name="FormName" id="FormName" >

<!-- ----------------------------All textfields/checkboxes/textareas go here------ -->
<div style="text-align:left;"><br><big><big><span style="font-family: sans-serif;">PERSONAL HEALTH RISK ASSESSMENT-SCREENING</span></big></big><br>
</div></div><br>

<input name="Clinic" class="noborder normaltext" style="width: 400px; font-size: 14px; font-weight: bold" oscardb=clinic_name type="text"><br>
<strong>Date: &nbsp;</strong> <input name="TodayDate" class="noborder normaltext" style="" oscardb=today type="text"><br>
<strong>Name:</strong> <input name="PatientName" class="noborder normaltext" style="width: 400px" oscardb=first_last_name type="text">
<strong>Age:</strong> <input name="Age" class="noborder normaltext" style="width: 60px" oscardb=Age type="text"><br>
<br>

<!-- ------------------------------------------------------------------ -->
<strong>Risk Factors:</strong> <a href="http://www.quitnow.ca/" target="_blank">Smoking</a> (786)<input name="Riskfactors1" type="checkbox">; Unhealthy <a href="http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php" target="_blank">Diet </a> (783)<input name="Riskfactors2" type="checkbox">; Physically <a href="http://www.actnowbc.ca/" target="_blank">Inactive</a> (785)<input name="Riskfactors3" type="checkbox">; Medical <a href="http://www.healthlinkbc.ca/dietitian/" target="_blank">Obesity</a> (783)<input name="Riskfactors4" type="checkbox"><br>
<ul>


<!-- ----------------Measurements-------------------------------- -->
  <li>Fill out below. Or see measurements as documented on file and attached <input name="Riskfactors5" type="checkbox"></li>
  <ul>
    <li>Height: <input class="noborder" name="Riskfactors6"style="width: 60px"  oscarDB=m$HT#value type="text"> Weight: <input class="noborder" name="Riskfactors7" style="width: 60px" oscarDB=m$WT#value type="text"> <a href="http://www.mcw.edu/calculators/bodymassindex.htm" target="_blank">BMI</a>: <input class="noborder" name="Riskfactors8" style="width: 40px" oscarDB=m$BMI#value type="text"> Waist: <input class="noborder" name="Riskfactors9" style="width: 60px" oscarDB=m$WAIS#value type="text"></li>
    <li>Total Cholesterol: <input class="noborder" name="Riskfactors10"style="width: 40px" oscarDB=m$TCHL#value type="text"> LDL (bad): <input class="noborder" name="Riskfactors11"style="width: 40px" oscarDB=m$LDL#value type="text"> HDL (good): <input class="noborder" name="Riskfactors12" style="width: 40px" oscarDB=m$HDL#value type="text"> Triglyceride: <input class="noborder" name="Riskfactors13"style="width: 40px" oscarDB=m$TG#value type="text"></li>
    <li>Blood Pressure: <input class="noborder" name="Riskfactors14"style="width: 80px" oscarDB=m$BP#value type="text"> FBS: <input class="noborder" name="Riskfactors15"style="width: 40px" oscarDB=m$FBS#value type="text"> Diabetes screen: <input class="noborder" name="Riskfactors16"style="width: 60px" type="text"></li>

  </ul>
  <li>Cardiovascular<a href="http://www.evidocs.ca/riskcalc/" target="_blank"> risk score</a> (likelihood of heart attack in next 10 years): <input class="noborder" name="Riskfactors17"style="width: 200px" type="text"></li>
  <li><a href="http://www.idf.org/node/1405?unode=4A7F23CB-FA35-4471-BB06-0294AD33F2FC" target="_blank">Metabolic Syndrome </a>present: <input class="noborder" name="Riskfactors18"style="width: 459px" type="text"></li>
</ul>


<!-- ------------------Action Plan------------------------------ -->
<strong><big>
<small>Action plan:</small></big></strong> 
<ul>
  <li>Diet modification: &nbsp;<a href="http://www.healthlinkbc.ca/dietitian/" target="_blank">Dietitian</a>&nbsp; -&nbsp; <a href="http://www.heartandstroke.bc.ca/site/c.kpIPKXOyFmG/b.3644427/k.3988/Healthy_Living__Healthy_Eating.htm" target="_blank">Healthy Eating<br>
    </a></li>
  <ul>
    <li>Five servings of fruit and vegetables per day <input name="ActionPlan1" type="checkbox"><br>
    </li>
    <li>Low saturated fats, trans fats, and cholesterol (&lt;300 mg per day) <input name="ActionPlan2" type="checkbox"></li>
    <li>Low carbohydrates and sugar, high fibre and whole grain <input name="ActionPlan3" type="checkbox"></li>
    <li>Low salt (&lt; 1/2 teaspoon per day) <a href="http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/b.4119695/k.51B/Healthy_Living__The_DASH_Diet_to_lower_blood_pressure.htm" target="_blank">Dash Diet</a> <input name="ActionPlan4" type="checkbox"></li>
    <li>Increase Omega-3 fatty acids (e.g. fish), 2 servings per week <input name="ActionPlan5" type="checkbox"></li>
  </ul>
  <li>Exercise recommendation: <a href="http://www.heartandstroke.bc.ca/site/c.kpIPKXOyFmG/b.3644685/k.50F4/Healthy_Living__Physical_Activity.htm" target="_blank">Healthy Exercise</a> - <a href="http://www.actnowbc.ca/" target="_blank">ActNowBC</a><br>
  </li>
  <ul>
    <li>start at <input class="noborder" name="ActionPlan6"style="width: 60px; text-align: center" type="text"> min <input class="noborder" name="ActionPlan7"style="width: 60px; text-align: center" type="text"> times per week&nbsp;</li>
    <li>increase to <input class="noborder" name="ActionPlan8"style="width: 60px; text-align: center" type="text"> min <input class="noborder" name="ActionPlan9"style="width: 60px; text-align: center" type="text"> times per week&nbsp;</li>
  </ul>
  <li>Weight loss&nbsp;<a href="http://www.heartandstroke.bc.ca/site/c.kpIPKXOyFmG/b.3644995/k.3225/Healthy_Living__Healthy_Weight.htm" target="_blank">Healthy Weight</a></li>
  <ul>
    <li>Target weight loss of <input class="noborder" name="ActionPlan10"style="width: 60px; text-align: center" type="text"> by <input class="noborder" name="ActionPlan11"style="width: 80px; text-align: center" type="text"> (short term)&nbsp;</li>
    <li>Target weight loss of <input class="noborder" name="ActionPlan12"style="width: 60px; text-align: center" type="text"> by <input class="noborder" name="ActionPlan13"style="width: 80px; text-align: center" type="text"> (long term, BMI &lt;27)&nbsp;</li>
  </ul>
  <li>Smoking cessation <a href="http://www.quitnow.ca/">QuitNow.ca</a> Call 1-877-455-2233</li>
  <ul>
    <li>Follow up appointment to discuss smoking cessation <input name="ActionPlan14" type="checkbox"></li>
    <li>If ready, identify quit date: <input class="noborder" name="ActionPlan15"style="width: 150px" type="text"></li>
    <li>Smoking cessation method: <input class="noborder" style="width: 400px;" name="ActionPlan16" type="text"></li>
  </ul>
</ul>


<!-- -----------------Follow-Up Date----------------------------------- -->
<strong>Follow-up appointment:</strong> <strong><input class="noborder" style="width: 400px;" name="FUappt" type="text"><br><br>
Repeat lab tests: <input class="noborder" style="width: 400px;" name="repeat tests" type="text"> When: </strong><input  class="noborder" name="when"style="width: 150px" type="text"><br><br>


<!-- ---------------Other Screening------------------------------------- -->
<strong>Other suggested screening:</strong>
<ul>
  <li><a href="http://www.bcguidelines.ca/gpac/pdf/colorectal_det.pdf" target="_blank">Colorectal cancer screening </a>(q1-2 years after age 50) <input name="otherscreening1" type="checkbox"></li>
  <li><a href="http://www.bcguidelines.ca/gpac/guideline_mammography.html#recommendation2" target="_blank">Mammography</a> (q1-2 years from age 40-79) <input name="otherscreening2" type="checkbox"></li>
  <li><a href="http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Gynecology/UterineCervix1of2/4Screening.htm" target="_blank">Pap</a> smear (q1-2 years from sexually active until age 69) <input name="otherscreening3" type="checkbox"> </li>
  <li>High <a href="http://www.bcguidelines.ca/gpac/guideline_hypertension.html" target="_blank">blood pressure</a> (screen yearly) <input name="otherscreening4" type="checkbox"></li>
  <li>Discuss use of <a href="http://www.bcguidelines.ca/gpac/guideline_cvd.html" target="_blank">ASA</a> (Framingham risk &gt;20%, age &lt;70) <input name="otherscreening5" type="checkbox"></li>
</ul>


<!-- ---------------Adult Immunizations------------------------------------- -->
<strong>Adult immunizations:</strong><br>
<ul>
  <li>Influenza (annually if at risk) <input name="immunizations1" type="checkbox"></li>
  <li>Pneumococcal vaccine (if at risk and q5-10 years; or age 65 once) <input name="immunizations2" type="checkbox"></li>
  <li>Tetanus/Diphtheria vaccine (q10 years; preferably Adacel) <input name="immunizations3" type="checkbox"></li>
</ul>


<!-- ---------------Comments------------------------------------- -->
<textarea style="height: 100px; width: 750px; font-weight: bold; font-size: 18px" cols="1" rows="1" name="Comments" type="text">Comments:  </textarea>
<br><br>

<strong>Helpful Web Resources for Patients:</strong><br>	
<ul>
  <li>Smoking cessation: www.quitnow.ca</li>
  <li>Canada Food Guide: www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php</li>
  <li>Dietitian web resource: www.healthlinkbc.ca/dietitian</i>
  <li>ActNowBC: www.actnowbc.ca</li>
</ul>

<!-- The submit/print/reset buttons -->
 <div class="DoNotPrint" id="BottomButtons" style="">
	 <table><tr><td>
		 Subject: <input name="subject" size="40" type="text"> 
			<input value="Submit" name="SubmitButton" id="SubmitButton" type="submit" onclick=" releaseDirtyFlag();"> 
			<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
			<input value="Print" onclick="window.print()" type="button">
			<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="window.print(); document.FormName.submit()">

	 </td></tr></table>
 </div>
 </form>
</body>
</html>

Document Actions

 

Download button

DOWNLOAD OSCAR FOR TESTING

 

eForms button

DOWNLOAD SHARED E-FORMS


 Customize button

FIND PLUG-INS AND TWEAKS
FOR YOUR OSCAR EMR

 

Subscribe Button

SUBSCRIBE TO DISCUSSION LIST 
(SEE ALL LISTS)

  

Help button

ACCESS THE ONLINE MANUALS
(PAID SUPPORT)