PERSONAL HEALTH RISK ASSESSMENT-SCREENING
Date:
Name:
Age:
Risk Factors:
Smoking
(786)
; Unhealthy
Diet
(783)
; Physically
Inactive
(785)
; Medical
Obesity
(783)
Fill out below. Or see measurements as documented on file and attached
Height:
Weight:
BMI
:
Waist:
Total Cholesterol:
LDL (bad):
HDL (good):
Triglyceride:
Blood Pressure:
FBS:
Diabetes screen:
Cardiovascular
risk score
(likelihood of heart attack in next 10 years):
Metabolic Syndrome
present:
Action plan:
Diet modification:
Dietitian
-
Healthy Eating
Five servings of fruit and vegetables per day
Low saturated fats, trans fats, and cholesterol (<300 mg per day)
Low carbohydrates and sugar, high fibre and whole grain
Low salt (< 1/2 teaspoon per day)
Dash Diet
Increase Omega-3 fatty acids (e.g. fish), 2 servings per week
Exercise recommendation:
Healthy Exercise
-
ActNowBC
start at
min
times per week
increase to
min
times per week
Weight loss
Healthy Weight
Target weight loss of
by
(short term)
Target weight loss of
by
(long term, BMI <27)
Smoking cessation
QuitNow.ca
Call 1-877-455-2233
Follow up appointment to discuss smoking cessation
If ready, identify quit date:
Smoking cessation method:
Follow-up appointment:
Repeat lab tests:
When:
Other suggested screening:
Colorectal cancer screening
(q1-2 years after age 50)
Mammography
(q1-2 years from age 40-79)
Pap
smear (q1-2 years from sexually active until age 69)
High
blood pressure
(screen yearly)
Discuss use of
ASA
(Framingham risk >20%, age <70)
Adult immunizations:
Influenza (annually if at risk)
Pneumococcal vaccine (if at risk and q5-10 years; or age 65 once)
Tetanus/Diphtheria vaccine (q10 years; preferably Adacel)
Comments:
Helpful Web Resources for Patients:
Smoking cessation: www.quitnow.ca
Canada Food Guide: www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php
Dietitian web resource: www.healthlinkbc.ca/dietitian
ActNowBC: www.actnowbc.ca
Subject: