Houston: Eligibility Screening Form1:Hpertension and Diabetes

OMB No. 0990-

Exp. Date XX/XX/20XX

ELIGIBILITY SCREENING FORM: HYPERTENSION AND DIABETES

(Completed by Program Staff at Time of Recruitment)

Patient Centered Care Collaboration to Improve Minority Health Initiative

[Houston Hub]

Conducted by Texas Southern University College of Pharmacy and Health Sciences

Step I. - Recruitment Location (please indicate by checking below)

• Telephone Date: ________________

• Lyerly

• Bellerive

• Historic Oaks of APV

Step II. – Eligibility Section (please ask the patient the following questions to determine eligibility)

Do you have: high blood pressure? diabetes?	Y Y	N N
Are you taking at least one medication for: high blood pressure? diabetes?	Y Y	N N
3. Are you age 55 or older?	Y	N
What is your race/ethnicity? □ African-American □ Asian-American □ Hispanic/Latino
5. Are you a resident of (mention facility name checked in Step I)? 5a. If no, please indicate facility name: _________________________	Y	N
6. Do you have regular access to a telephone? For telephone follow-up	Y	N

Step III. - Determine patient eligibility. (Patient eligible, only if Yes to all questions above)

• If answered “No” to any of the questions above, the patient is not eligible:

• Use the following text to end the encounter with the patient: “Thank you for your time. You are not eligible to participate in the study at this time.”

• If answered “Yes” to all questions above, please continue to Step IV below

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 15 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Step IV. – Patient Demographics:

Sex:  Male  Female

Patient Name (Last, First): _________________________________________________________________

Phone number 1: _____________________________ Phone Number 2: _____________________________

Address: _______________________________________________________________________________

Date of Birth (MM/DD/YYYY): _________________________

Race/Ethnicity: _______________________________________

Please mark preferred spoken language:

□ English □ Spanish □ Vietnamese □ Cantonese □ Mandarin

Please mark preferred written language:

□ English □ Spanish □ Vietnamese □ Cantonese □ Mandarin

What is the highest level of education that you have completed?

• Middle school or lower

• High School

• Associate Degree

• Technical School Certification

• Four-year College Degree

• Graduate School

For telephone follow-up

When is a good time to come for a home visit (Circle all that apply)?

Monday AM PM Saturday AM PM

Tuesday AM PM Sunday AM PM

Wednesday AM PM

Thursday AM PM

Friday AM PM

Date: ____________________

Client ID #: ____________________

Step V. –PCCC Items:

We would like to know how you heard about this health program. Please check all answers that apply.
1. How did you learn about this health program?
Through personal contact with a: □ Friend, neighbor, or relative □ Health care professional □ Social service professional □ Other ________________________________________________________
Through written materials I read: □ Brochure □ Direct mail □ Other _______________________________________________________
Through social media/electronic materials I read: □ Email □ Telephone text message □ Facebook posting □ Other _______________________________________________________
The statements below describe attitudes and beliefs you may have about why you signed up for the health program and about your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.	1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5 = I strongly agree
	1	2	3	4	5
2. Why did you sign up for the program?
I need help managing my health condition
I need information on my health condition
The classes will be taught by a trained professional (community health worker, health educator, pharmacist)
The class will be taught in my language
The materials will be written in my language
Someone will call me to follow-up on what I learn and remind me of what I should do to manage my health
It is easy to get to the program location
It will not take a lot of my time
It does not cost me anything

Step VI. – Baseline Data Collection

1. Past Medical History

a. What conditions have you been diagnosed with in the past?
1. _______________________________ 5. ___________________________________________
2. _______________________________ 6. ___________________________________________
3. _______________________________ 7. ___________________________________________
4. _______________________________ 8. ___________________________________________

b. Have you had the following conditions within the past 6 months?

• Stroke

• Heart attack

• Chest pain

• Vision problems

• Kidney disease

• Peripheral vascular disease

• Unusual weight loss

• Cuts/bruises that are slow to heal

• Tingling numbness in the hands/feet

• Recurring skin, gum, or bladder infections

• Hospital admission due to high blood pressure/diabetes

• Emergency room visits due to high blood pressure/diabetes

• Physicians office visits due to high blood pressure/diabetes

• Adverse events caused by high blood pressure/diabetes medications

2. Social History:

 Smoking (______ packs per day for _______ years)

 Alcohol (what kind? ________________ how often?_______)

 Illicit drug use (such as: _____________________________)

3. Do you have any history of an allergic drug reaction?

Drug Name: _____________________________Type of reaction: ______________________________

________________________________________________________________________________­­­­_____

4. Do you have a primary care physician?  Yes  No

*Note: If no primary care physician, please refer to Harris County Hospital District.

5. If yes, to question #4, who is your primary care physician?

PCP Name: _______________________ Phone:_____________________ Fax :______________________

Address: _______________________________________________________________________________

6. Is your doctor from Harris County Hospital District?  Yes  No

7. Are you okay with us contacting your physician to let him/her know you are participating in this program and inform them about any irregular findings?  Yes  No

8. Are these needed?

__________________________________________________________________________________

Self Monitoring Questions (please refer to appropriate section below):

9. Behavior - pre/post changes

Hypertension:

10. Do you have a blood pressure machine at home?  Yes  No

11. How often do you monitor your blood pressure?

• More than one time per day

• Daily

• Weekly

• Monthly

• Never

12. If “Never” to question #11, what is the reason for not monitoring your blood pressure at home? (Check all that apply)

• Unable to purchase a machine

• Health related disability (e.g. arthritis, poor vision)

• Not sure how to use the machine

• Lack of help

• Time

• Not important

• Don’t know

13. On average, how often do you see your health care professional for your blood pressure?

• Every Week

• Every Month

• Quarterly

• Every year

• Never

• Don’t know

Diabetes:

14. Do you have a glucose meter at home?  Yes  No

15. How often do you monitor your blood sugar?

• More than one time per day

• Daily

• Weekly

• Monthly

• Never

16. If “Never” to question #15, what is the reason for not monitoring your blood sugar at home? (Check all that apply)

• Unable to purchase a machine

• Health related disability (e.g. arthritis, poor vision)

• Not sure how to use the machine

• Lack of help

• Time

• Not important

• Don’t know

17. On average, how often do you see your health care professional for your diabetes?

• Every Week

• Every Month

• Quarterly

• Every year

• Never

• Don’t know

18. Are you currently participating in any exercise program?  Yes  No

19. Are you currently participating in any diet program?  Yes  No