Diabetes and Cardiovascular
DEMOGRAPHICS & CLINICAL MEASUREMENTS
AMRS ID Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
RISK FACTORS ASSESSMENT
Age & gender
Female:
...
<35 years
>35 years
Male:
...
<40 years
>40 years
Weight (kg):
HEIGHT (CM):
BMI:
kg/m
2
≥ 25kg/m
2
?
Yes
No
Waist circumference (cm) :
Men
≥94cm? Women ≥80cm?
Yes
No
Blood pressure (BP):
mmHg S≥140? or D>90?
Yes
No
Encounter Details
Location Name:
*
Provider ID:
Provider's system-id:
*
Encounter Date:
*