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Center for Nutrition and Diabetes Management Cardiovascular Risk Assessment Name: _______________________________________________ Date: _____________________ Gender: Male Female Other DOB: _____________________ The most important things I want to learn/concerns I have: manage my cholesterol/lipids manage my weight plan meals use a PT/INR meter eat healthy/follow healthy diet portion control take better care of myself be consistent with exercise read food labels quit smoking avoid complications paying for supplies other: _________________________________________________________________________ Current Height: _______ Weight: _______ Self Monitoring Skills: 1. Do you check your weight regularly? ❒ No ❒ Yes How often? _________________________ 2. What is your usual weight range? ________ 3. Have you gained or lost weight recently? ❒ No ❒ Yes If so, how much? __________________ 4. Do you record your results? ❒ No ❒ Yes If yes, where: ___________________________ 5. What do you do if your weight is higher or lower? ❒ Adjust medication dose _______________ ❒ Call my doctor ❒ Nothing ❒ Adjust diet ❒ Other _____________________________ 6. Do you check your blood pressure? ❒ Yes ❒ No 7. If yes h Never 8. What is your usual blood pressure range? ____________________________________________ 9. What do you do if your reading is high or low? ________________________________________ Learning Needs: 1. How do you like to learn? ❒ Reading ❒ Discussion ❒ Hands on training ❒ Role playing ❒ Internet ❒ Lecture ❒ Videos or DVDs 2. Education level? ❒ Grammar ❒ High school ❒ College ❒ Advanced degree(s) 3. Do you have and problems with hearing, vision or speech ? ❒ No ❒ Yes Please explain: ______________________________________________________________ Nutrition: 1. Have you ever struggled with: ❒ Bulimia 2. What have you done about this? ____________________________________________________ 3. Do you have any problems with: ❒ Gums ❒ Problems chewing ❒ Dentures 4. Who prepares your meals for you? ___________________________________________________ 5. How many times a week do you eat away from home? __________________________________ ❒ Fast food ❒ Restaurant ❒ Take out ❒ Other 6. Do you: ❒ Skip meals ❒ Nibble between meals ❒ Eat rapidly ❒ Have food cravings ❒ Use convenience foods ❒ Eat unplanned meals ❒ Other 7. What are your main beverages? _____________________________________________________ 8. Are you currently on a special diet? ❒ No ❒ Yes If so, what? ___________________________ Exercise: 1. Do you exercise regularly? ❒ No ❒ Yes. What kind of exercise do you do? _____________ 2. How often: For how long? _______________________________ D:\582778098.doc 1 of 4 edications: List all medications, vitamins, herbs and supplements you are taking: Name Dose When Taken Taking it as prescribed Yes/No Attach additional sheets if necessary. If not taking medications as prescribed, what are your concerns? ____________________________ other (please explain): ______________________________________________________________ Do you take an aspirin daily? ❒ No ❒ Yes (dose:__________) Have you had the following immunizations? ❒ Flu shot Pneumonia (65 years and over) Zoster T-dap Meningococcal Hepatitis A Hepatitis B Varicella MMR Medicine Allergies: _______________________________________________________________ Food Allergies: ___________________________________________________________________ Family History: __________________________________________________________________ Your History: ❒ Heart problems ❒ High blood pressure (greater than 130/80 mmHg) ❒ High Stress ❒ High cholesterol and or lipids Diabetes Thyroid Kidney disease Cancer Liver disease Lung disease Other ___________________________________________________________________ Major Surgery ____________________________________________________________ Other Problems: _________________________________________________________________________________ Cardiovascular History: 1. Have you ever had health education (by a nurse)? ❒ No ❒ Yes If so when? ____________ 2. Have you ever had nutrition education? No Yes If so when __________________ 3. Are there any religious or cultural factors that affect your health? ❒ No ❒ Yes Explain:____________________________________________________________________ 4. When were you diagnosed with your current condition? _________________________________ 5. What is your understanding of your condition? ________________________________________ 6. Have you had any recent hospital visits? ❒ Yes ❒ No Please describe: _____________________________________________________________ 7. Have you ever had chest pain, angina, and or a heart attack? ❒ Yes ❒ No If yes, please explain _________________________________________________________ 8. Have you had an exercise stress test? ❒ No ❒ Yes When? _______________________ 9. Have you had an EKG? ❒ No ❒ Yes When? _______________________ 10. Have you had a heart catherization? ________ If so, when and what was done? ______________ D:\582778098.doc 2 of 4 _________________________________________________________________________________ 11. Last appointment with health care provider for: Last eye exam: __________ Last dental exam: ________ Last foot exam: _________ 12. Do you carry a medication with you? __________________________ ❒ No ❒ Yes 13. Do you wear medical identification? ❒ No ❒ Yes What? Describe:________________________ Cardiovascular symptoms: 1. Have you had any of the following signs/symptoms? ❒ Chest pain ❒ Chest pressure ❒ Sweating ❒ Anxiety ❒ Dizziness ❒ Nausea ❒ Shortness of breath ❒ Pass out ❒ Skipping beats ❒ Weakness ❒ Uncontrolled blood pressure ❒ Fast heartbeat ❒ Palpations ❒ High blood sugars ❒ Leg ulcers ❒ Fluid in feet/legs ❒ Poor circulation ❒ Blood clots ________ 3. Why do you get heart symptoms? ❒ Too much activity ❒ Unexplained ❒ Stress ❒ Other ___________________________________________________________________ 4. How do you treat it? ❒ Nothing ❒ Rest ❒ Take medication _________________ ❒ Call doctor ❒ Go to the Emergency Room Anticoagulant Use: 1. Do you take Coumadin, Heparin, Lovenox, or other anti-coagulant medication? ❒ No ❒ Yes If yes: pill Lovenox or Heparin injections 2. How long have you been on this medication? ________________________________________ 3. Who prescribes it?_______________________________________________________________ 4. If using injectable medication who gives the injection? __________________________________ 5. Where do you inject? ❒ Arm ❒ Abdomen ❒ Thigh 6. Are you enrolled in the Community Safe Syringe Program? 7. Do you skip or adjust your anticoagulant medication? 8. If yes, why? ❒ Forget to take it ❒ Yes ❒ No ❒ Yes ❒ No ❒ Can’t afford it ❒ Ran out of it ❒ Follow physician orders for adjustment 9. Have your lab results been within the recommended range? ❒ Yes ❒ No Alcohol/Nicotine/: 1. Do you drink alcohol? ❒ No ❒ Yes How much? _________________________________ How often? ________________________________________________________________ 2. Do you use any nicotine products? ❒ Yes ❒ No If yes: ❒ Smoke cigarettes ❒ Chew tobacco ❒ cigars ❒pipe ❒Chew or dip tobacco 3. How much? ____________________________________________________________________ D:\582778098.doc 3 of 4 4. If you stopped smoking/chewing, how long ago did you quit? ____________________________ 5. If you have not stopped smoking/chewing, do you want to stop? ❒ Yes ❒ No 6. Do you currently use any drugs not prescribed for you? ❒ No ❒ Yes ❒ Marjijuana ❒Stimulants (cocaine, speed) ❒ sedatives (valium, xanax, ativan, etc) ❒ Heroin ❒ Methadone ❒ pain pills (Percocet, oxy, vicodin, etc) ❒ Other If so, how often? ____________________________________________________________ Living and Working Situation: 1. With whom do you live? ❒ Alone ❒ Spouse ❒ Significant Other 2. Do you have support in your health management? If yes who: ___________________________ 3. Are you currently employed? ❒ No ❒ Yes Type of Job: _____________________________ 4. Are you are retired? ❒ No ❒ Yes What was your previous job? ______________________ 5. Are you a student? ❒ No ❒ Yes Major? ________________________________________ 6. Current stress level (0 none – 10 very high) ________ Sleep Problems: Do you have any sleep problems? ❒ No ❒ Yes If yes, do you have: ❒ Snoring ❒ Restless sleeping ❒ Periods of not breathing when sleeping ❒ Sleep deprivation due to snoring ❒ Feeling not rested and tired during the day ❒ Trouble getting to sleep/insomnia ❒ Sleep Apnea ❒ CPAP machine (use it?) ___________ Feelings and Concerns: 1. How do you feel about having cardiovascular disease? ❒ Okay ❒ Anxious ❒ Angry ❒ Overwhelmed ❒ Sad ❒ Afraid ❒ Depressed ❒ Unsure of what to do ❒ Other Depression: 1. Have you recently felt down, depressed, hopeless or have little or no interest/pleasure in doing things? ❒ Yes ❒ No 2. Are you being treated for depression? ❒ Yes ❒ No Would you like a referral to speak to someone? __________________________________________ Pain Assessment: 1. Do you have a condition that causes pain? ❒ Yes 2. If yes, is it being managed effectively by your doctor? ❒ Yes ❒ No Please explain: ______________________________________________________________ 3. How does the pain affect your life? _________________________________________________ Women’s Health: Menstrual Status: Child bearing ❒ Perimenopausal Questions you want answered: ________________________________________________________________________________ ________________________________________________________________________________ D:\582778098.doc 4 of 4 The following information is confidential. Thank you for taking the time to fill out this information. _________________________________________________________________________________ Patient Signature Date _________________________________________________________________________________ Nurse Health Educator Signature Date _________________________________________________________________________________ Nutritionist Signature Date D:\582778098.doc 5 of 4