PRIMARY PREVENTION PROGRAM FOR CARDIOVASCULAR DISEASE

DEVELOPED BY GRAVITIDE

CARDIOLOGY UNIT, TEACHING HOSPITAL, BATTICALOA

PERSONAL DETAILS
First Name
Last Name
Date of Birth

Date____________ | Month____________ | Year____________

Sex

Male | Female

Age
Address
DS Division
NIC
Phone Number
Job

Permanent | Temporary | Daily Basis | Self Employed | Jobless

Job Type

Sedentary | Active

Income

EXTRA DETAILS
Marital Status

Single | Married | Widow | Widower

Number of Children
Emotional Support

Average | Good | Low

Economical Support

Average | Good | Low

Water Source

Well | River | Water Supply | Other

Water Type

Boiled & Filtered | Boiled | Filtered | Raw

Expected Cardiovascular
Disease Events in 10 years

<10% | 10%-20% | 20%-30% | >30%

DIET DETAILS
Cholesterol / Oily Food

High | Moderate | Low

Fruits & Vegetables

High | Moderate | Low

Alcohol Intake

High | Moderate | Low | Nil

PARENTS DETAILS - DURING CHILDHOOD AND ADOLESCENCE

Fathers Education

Not Educated | School | High School | Diploma | Degree

Fathers Job

Government | Manual Business | Sedentary Business | No Job

Mothers Education

Not Educated | School | High School | Diploma | Degree

Mothers Job

Government | Manual Business | Sedentary Business | No Job

Living Standard At The Time

Poor | Lower Middle Class | Middle Class | Upper Middle Class | Rich

Living Area At The Time

Village | Suburban | Urban

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PRIMARY PREVENTION PROGRAM FOR CARDIOVASCULAR DISEASE

DEVELOPED BY GRAVITIDE

CARDIOLOGY UNIT, TEACHING HOSPITAL, BATTICALOA

OBSERVATION DETAILS OF RISK PROFILE

Observation Note
Date of Observation

Date____________ | Month____________ | Year____________

DIABETES DETAILS
Have Diabetes

Yes | No

If, How Long / Period

Following Clinic

Yes | No

ESTABLISHED CORONARY ARTERY DISEASE DETAILS

Have STEMI

Yes | No

Have NSTEMI

Yes | No

Have Unstable Agnia

Yes | No

Have Prior Revascularization

Yes | No

Have Angina

Yes | No

Have PVD

Yes | No

Have Stroke

Yes | No

Following Clinic

Yes | No

LIPIDS PROFILE DETAILS

TC
LDL
HDL
TG
NHC

SMOKING DETAILS
Is Smoking

Yes | No

Type

Cigarette | Beedi | Cigar | Other

Frequency (pack years)

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PRIMARY PREVENTION PROGRAM FOR CARDIOVASCULAR DISEASE

DEVELOPED BY GRAVITIDE

CARDIOLOGY UNIT, TEACHING HOSPITAL, BATTICALOA

HYPERTENSION DETAILS
Have Hypertension

Yes | No

Following Clinic

Yes | No

MINOR RISK FACTORS DETAILS

ABI
Cardio Intimal Thickness
HS CRP
Albuminuria
Apolipoprotien B
Homocystein
CA Score

OTHER RISK FACTORS DETAILS

Have Heart Disease History

Yes | No

Waist Circumference (cm)

Weight
Height
BMI
Physical Activity

Sedentary | Active

OTHER NOTES

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