ANNEX C

PHILPEN RISK ASSESSMENT FORM (REVISED 2022)

Adults ≥20 years old

Name of Health Facility: Date of Assessment:

I. PATIENT’S INFORMATION
Patient Name: (Surname, Given Name, Middle Name) Age: Sex: Birthdate:

PHIC No.: Civil Status: Religion: Contact No.:

Patient's Address:
Persons with Disability ID Card No., if applicable: Employment Status: [ ] Employed [ ] Unemployed [ ] Self-employed

[ ] IP [ ] Non-IP Ethnicity:
II. ASSESS FOR RED FLAGS
2.1 Chest Pain [ ] Yes [ ] No
2.2 Difficulty of Breathing [ ] Yes [ ] No
2.3 Loss of Consciousness [ ] Yes [ ] No
2.4 Slurred Speech [ ] Yes [ ] No
2.5 Facial Asymmetry [ ] Yes [ ] No
If YES to ANY, REFER IMMEDIATELY to a
2.6 Weakness/ Numbness on arm of left on one side of the body [ ] Yes [ ] No Physician for further management and/or
2.7 Disoriented as to time, place and person [ ] Yes [ ] No referral to the next level of care
2.8 Chest Retractions [ ] Yes [ ] No
If ALL answers are NO, proceed to Part III.
2.9 Seizure or Convulsion [ ] Yes [ ] No
2.10 Act of self-harm or suicide [ ] Yes [ ] No
2.11 Agitated and/or aggressive behavior [ ] Yes [ ] No
2.12 Eye Injury/ Foreign Body on the eye [ ] Yes [ ] No
2.13 Severe Injuries [ ] Yes [ ] No
III. PAST MEDICAL HISTORY
3.1 Hypertension [ ] Yes [ ] No
3.2 Heart Diseases [ ] Yes [ ] No
3.3 Diabetes [ ] Yes [ ] No
3.4 Cancer [ ] Yes [ ] No
3.5 COPD [ ] Yes [ ] No
3.6 Asthma [ ] Yes [ ] No
3.7 Allergies [ ] Yes [ ] No
3.8 Mental, Neurological, and Substance-Abuse Disorders [ ] Yes [ ] No
3.9 Vision Problems [ ] Yes [ ] No
3.10 Previous Surgical History [ ] Yes [ ] No
3.11 Thyroid Disorders [ ] Yes [ ] No
3.12 Kidney Disorders [ ] Yes [ ] No
IV. FAMILY HISTORY
4.1 Hypertension [ ] Yes [ ] No
4.2 Stroke [ ] Yes [ ] No
4.3 Heart Disease (changed from “Cardiovascular”) [ ] Yes [ ] No
4.4 Diabetes Mellitus [ ] Yes [ ] No
4.5 Asthma [ ] Yes [ ] No
4.6 Cancer [ ] Yes [ ] No
4.7 Kidney Disease [ ] Yes [ ] No
4.8 1st degree relative with premature coronary disease or vascular disease
[ ] Yes [ ] No
(includes “Heart Attack”)
4.9 Family members having TB in the last 5 years. [ ] Yes [ ] No
4.10 Mental, Neurological and Substance Abuse Disorder. [ ] Yes [ ] No
4.11 COPD [ ] Yes [ ] No
V. NCD RISK FACTORS
[ ] Q1 Never Used (proceed to Q2)
[ ] Q2 Exposure to secondhand smoke
[ ] Q3 Former tobacco user (stopped smoking >1 year) If YES to Q2-Q4, follow the tobacco cessation
5.1 Tobacco Use [ ] Q4 Current tobacco user (currently smoking or stopped protocol (5As) and use Form 1. Tobacco Cessation
smoking <1year) Referral Protocol, if needed.

*Remove Option: number of packs used in smoking*

 If NO, congratulate the patient. The patient is at a
Q1. [ ] Never Consumed [ ] Yes, drinks alcohol
lower risk of drinking alcohol.
If YES, proceed using AUDIT SCREENING TOOL
(Form 2) to assess alcohol consumption and alcohol
5.2 Alcohol Intake problems.
Q2. Do you drink 5 or more standard drinks for men, and 4 or
If YES, provide brief advice and/or extended brief
more for women (in one sitting/occasion) in the past year?
advice. The patient is on the higher risk category
[ ] Yes [ ] No
level of drinking or in harmful use of alcohol.

If NO or patient does not reach the recommended

Does the patient do at least 2.5 hours a week of moderate-
hours/week off moderate-intensity physical activity,
5.3 Physical Activity intensity physical activity?
give lifestyle modification advice following Annex 1.
[ ] Yes [ ] No
Healthy Lifestyle Module.

Q1. Does the patient eat high-fat, high-salt food

If YES to the question, give lifestyle modification
(processed/fast food such as instant noodles, burgers, fries,
5.4 Nutrition and advice following Annex 2. Nutrition Practice
dried fish), "ihaw-ihaw/fried (e.g. isaw, barbecue, liver, chicken
Dietary Assessment Guidelines for Health Professionals in the Primary
skin) and high sugar food and drinks (e.g. chocolates, cakes,
Care Screening
pastries, soft drinks) weekly? [ ] Yes [ ] No
5.5 Weight (kg) 5.6 Height (cm) 5.7 Body Mass Index
(wt.[kgs]/ht.[cm]/ht.[cm]x10,000):
5.8 Waist Circumference (cm): 5.9 Blood Pressure (mmHg) obtained 2 readings at least 2 minutes apart.
M<90cm First Reading: Second Reading:
F<80cm

VI. RISK SCREENING

FBS Result:
Blood Sugar Date Taken:
RBS Result:
(write N.A. if not
applicable) CHECK if DM clinical symptoms are present:
[ ] Polyphagia [ ] Polydipsia [ ] Polyuria
6.1 Hypertension/ Total Cholesterol:
Diabetes/ HDL:
Hypercholesterolemia/ Lipid Profile LDL: Date Taken:
Renal Diseases VLDL:
Triglyceride:

Urinalysis/ Protein: Date Taken:

Urine Dipstick Test Ketones: Date Taken:

CHECK all applicable:

[ ] Breathlessness (or a "need for air") If YES to any of the symptoms, obtain peak expiratory flow rate
[ ] Chronic cough (PEFR). Give inhaled salbutamol, then repeat after 15 minutes.
6.2 Chronic Respiratory [ ] Sputum (mucous) production
Diseases [ ] Chest tightness*
(Asthma and COPD) [ ] Wheezing* Result:
[ ] >20% change from baseline (consider Probable Asthma)
* These symptoms may be episodic or [ ] <20% change from baseline (consider Probable COPD)
seasonal, vary over time and intensity and are
worse during night and early morning
VII. MANAGEMENT
Lifestyle Modification [ ] Yes [ ] No

Medications:
a. Anti-Hypertensives [ ] Yes [ ] No
b. Oral Hypoglycemic Agents/Insulin [ ] Yes [ ] No

Date of Follow-up: Remarks:

Assessed by: Assessed by:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

Name and Signature Name and Signature