Home Health Visit Data Collection Forms

Attachment 1j:

National Health Interview Survey (NHIS) Follow-up Health Study

Initial Report of Findings

Date of Home Visit: 6/1/2020

Participant Name: Jane Doe

Participant ID: 12345

This report provides you with results from today’s body and blood pressure measurements. You will receive your results from the laboratory blood and urine tests in the mail in several weeks.

The NHIS Follow-up Health Study visit is not intended to be a substitute for visits to your medical care provider. Your health care provider can help you understand your study results in the enclosed report.

Please keep this document in a safe place so that you can control who sees it. NCHS can only protect information that is inside NCHS systems.

If you have any questions about your results, you can call our Medical Officer, Dr. Tony Nguyen, toll-free at 1-833-872-0534 between 9:00 AM and 4:00 PM Eastern Time, Monday through Friday.

Body Measurements

Height: __5__ ft ___3_ inches

□ This measurement was not done for you during the home visit.

Weight:  ___123____ lbs.

□ This measurement was not done for you during the home visit.

Waist Circumference:  ____32___inches

□ This measurement was not done for you during the home visit.

Body Mass Index (BMI): _21.8___

The Body Mass Index (BMI) is used to define the categories of underweight, healthy weight, overweight, and obesity. BMI is calculated from measured height and weight using the formula below:

BMI=weight (lbs.) ÷ height (in.) ÷ height (in.) x 703.

Based on your height, your BMI is:

(The system will select the correct category based on the test result and display it on the computer screen for the health representative to circle below for the participant)

Body mass index National Institutes of Health (NIH) Statement

< 18.5 NIH classifies this as underweight.

18.5 – <25.0 NIH classifies this as a healthy weight.

≥25.0 - < 30.0 NIH classifies this as overweight.

≥ 30.0 NIH classifies this as obese.

• This measurement was not done for you during the home visit.

1. Your BMI and waist circumference measurements today indicate you are not at an increased risk for type 2 diabetes, high blood pressure, and cardiovascular disease. This is based on guidelines from NIH’s National Heart, Lung and Blood Institute

2. Your BMI and waist circumference measurements today indicate you are at an increased risk for type 2 diabetes, high blood pressure, and cardiovascular disease. This is based on guidelines from NIH’s National Heart, Lung and Blood Institute.

3. Your BMI and waist circumference measurements today indicate you are at a high risk for type 2 diabetes, high blood pressure, and cardiovascular disease. This is based on guidelines from NIH’s National Heart, Lung and Blood Institute.

4. Your BMI and waist circumference measurements today indicate you are at a very high risk for type 2 diabetes, high blood pressure, and cardiovascular disease. This is based on guidelines from NIH’s National Heart, Lung and Blood Institute.

5. Your BMI and waist circumference measurements today indicate you are at an extremely high risk for type 2 diabetes, high blood pressure, and cardiovascular disease. This is based on guidelines from NIH’s National Heart, Lung and Blood Institute.

Blood Pressure

Your Measurements Normal

Systolic Blood Pressure: __118____ mm Hg < 120

Diastolic Blood Pressure: __76____ mm Hg < 80

• This measurement was not done for you during the home visit.

Resting heart rate: __70___ beats per minute

• This measurement was not done for you during the home visit.

1. Your blood pressure today is within the normal range.*

2. Your blood pressure today is elevated. Based on national guidelines for the treatment of hypertension*, you should take this report to a health care provider within the next 3-6 months to have your blood pressure rechecked.

3. Your blood pressure today is high. Based on national guidelines for the treatment of hypertension*, you should take this report to a health care provider within two weeks.

4. Your blood pressure today is very high. Based on the national guidelines for the treatment of hypertension*, you should take this report to a health care provider within two weeks.

5. Your blood pressure today is severely high. Based on national guidelines for the treatment of hypertension*, this level warrants immediate attention by a health care provider. Our Medical Officer will contact you to answer any questions you may have.

*ACC/AHA Hypertension Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, American Journal of Hypertension, 31(2), 2018, p133-35.

These measurements were obtained as part of a health study and do not represent a medical diagnosis. Interpretation of these measurements must be made by your physician.