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