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Consultation Recipients
Please do not record any information regarding education - this form is strictly for consultation on patient results only.
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* Indicates required question
Patient ID
*
Your answer
What medications is patient taking?
*
Your answer
Please select if the participant receives the consultation in the following areas. 1=yes, 0=no
Metabolic Syndrome (MetS) 1=yes, 0=no
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1
0
Blood Pressure 1=yes, 0=no
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1
0
Blood Lipids 1=yes, 0=no
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1
0
Diabetes 1=yes, 0=no
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1
0
Bone Health 1=yes, 0=no
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1
0
HBV 1=yes, 0=no
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1
0
HCV 1=yes, 0=no
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1
0
Any others? (fill in)
Your answer
Follow-Up Action On-Site: Provided linkage-to-care for____________ (fill in medical conditions)
Your answer
For those without a PCP or access to healthcare, refer the patient to ________ (fill in the provider name or location)
Your answer
Follow-Up Action after Health Event
Need follow-up on MetS, DM, Lipids &/or BP 1=yes, 0=no
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1
0
Need follow-up on Viral Hepatitis 1=yes, 0=no
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1
0
Need follow-up on Osteoporosis 1=yes, 0=no
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1
0
Need follow-up on any others __________ (fill in)
Your answer
Initials of Recorder
*
Your answer
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