Address
REPUBLIC OF THE PHILIPPINES
LEGAZPI CITY HEALTH OFFICE
LEGAZPI CITY, ALBAY
MMM25 DATA CAPTURE FORM
Name of Patient Date of Birth Sex: ☐ Male
Age:___________
Diagnosis: ☐ HPN ☐ DM
☐
ESSENTIALLY NORMAL
Contact Number: _________________________________
RISK FACTOR: ☐ SMOKER ( TABACCO) ☐ SMOKER ( VAPE/ E-CIGARRETE)
☐BINGE DRINKER ☐OBESE ☐OVERWEIGHT
SCREENING SITE
☐ INSUFFICIENT PHYSICAL ACTIVITY ☐UNHEALTHY DIET Comorbidity: ☐ CKD ☐ STROKE
☐ELEVATED BLOOD PRESSURE ☐ELEVATED FASTING BLOOD SUGAR ☐ CANCER ☐ MENTAL HEALTH DISORDER
1a* Name of Country: 1b.* Name of City/Town/Village:
(Purok, Brgy)
2* Site ID (country code and site number) : _ _ _ / _ _ _
3 Where is your screening site? ☐ Hospital/Clinic ☐ Pharmacy ☐ Public area (indoors) ☐ Public area (outdoors)
☐ Home ☐ Workplace
…DD…/…MM…/…YY…
4* Date of measurement
BY COMPLETING THIS FORM, YOU CONSENT TO SHARE YOUR INFORMATION FOR ACADEMIC RESEARCH PURPOSES. PLEASE ANSWER ALL QUESTIONS. IF
YOU DO NOT KNOW THE ANSWER, LEAVE IT BLANK. DO NOT PROVIDE ANY PERSONAL DATA SUCH AS NAME, ADDRESS, OR PHONE NUMBER
☐ Mark with X if estimated
5* How old are you in years? (Estimate if Yrs
unknown)
6* What is your sex? ☐ Male ☐ Female ☐ Other
7* Ethnicity** (self-declared) ☐ Black ☐ White ☐ South Asian ☐ East/South East Asian ☐ Middle Eastern ☐ Mixed ☐ Other
8* When did you last have your blood pressure (BP) measured? ☐ Never ☐ Over 12 months ago ☐ Within the last 12 months
☐ Yes ☐ No
Have you ever been diagnosed with high BP by a health professional (except in
9*
pregnancy)?
10* Are you taking any BP medication? ☐ Yes ☐ No
10a* If you answered YES to Q10, how many different types of BP medication are you ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 + ☐ Don’t know
taking?***
a) Statin ☐ Yes ☐ No ☐ Don’t know
b) Aspirin ☐ Yes ☐ No ☐ Don’t know
11 Are you currently taking the following c) Warfarin/oral anticoagulant (blood thinners) ☐ Yes ☐ No ☐ Don’t know
medications?
12* If female, are you pregnant? ☐ Yes ☐ No
ABOUT THE PARTICIPANT
Do you use tobacco? (including chewing tobacco, cigarettes, cigars,
13 and pipes) ☐ Yes ☐ No – but I did in the past ☐ Never
14 Do you vape (e-cigarettes)? ☐ Yes ☐ No – but I did in the past ☐ Never
15 Do you consume alcohol? ☐ Never/rarely ☐ 1-3 times per month ☐ 1-6 times per week ☐ Daily
16 How often do you drink high caffeine drinks? ☐ Never or <4 per month ☐ 1-6 times per week ☐ 1-3 times per day ☐ 4+ per day
(e.g. coffee, energy drinks e.g. Red Bull, Redline)
a) Heart attack ☐ Yes ☐ No b) Stroke ☐ Yes ☐ No
17* Have you ever experienced or been diagnosed c) Heart failure ☐ Yes ☐ No d) Irregular heartbeat ☐ Yes ☐ No
as having…
e) Diabetes ☐ Yes ☐ No f) Kidney failure ☐ Yes ☐ No
Do you have a parent, brother or sister a) High blood pressure ☐ Yes ☐ No ☐ Don’t know
18
diagnosed with… b) Diabetes ☐ Yes ☐ No ☐ Don’t know
Do you take part in at least 150 mins of moderate exercise (brisk walking) or 75 mins
19 ☐ Yes ☐ No
of more vigorous exercise per week?
20 Did you know that potassium-rich (or reduced/low sodium) salt can lower BP? ☐ Yes ☐ No
21 How many years of education do you have? ☐ 0 ☐ 1-6 yrs ☐ 7-12 yrs ☐ over 12 yrs
22 Do you use a BP monitor at home? ☐ No ☐ Yes, an upper arm cuff monitor ☐ Yes, a wrist cuff monitor
22a If YES to Q22, how often do you use this ☐ <1 per month ☐ 1-3 times per month
monitor? ☐ 1-6 times per week ☐ ≥ 1+ per week
23* Weight (estimate if not measured) Kilograms (kg) OR Pounds (lbs) ☐ Mark with X if estimated
24* Height Metres (m) OR Feet/Inches ☐ Mark with X if estimated
25 What is your waist size? Centimetres (cm) OR Inches ☐ Mark with X if estimated
MEASUREMENTS
26 What is the manufacturer of the BP machine being used? ☐ OMRON ☐ Other
Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) Pulse
1st
27* measurement
2nd
measurement
3rd
measurement
* This is a mandatory question. Please ensure that all mandatory questions are answered.
**South Asian – with origins from: India, Pakistan, Bangladesh, Nepal, Bhutan, Maldives and Sri Lanka. East and South-East Asian – With Origins from any countries east of the Indian sub-continent.
***This means how many types of medications are being taken i.e. – ACE-inhibitors, ARBs, diuretics, beta-blockers, calcium channel blockers, alpha-blockers, others. If you are
unsure, please enter the number of different tablets each day. (If you are taking 1 tablet twice a day, this counts as 1).
