Form Physical Health In Physical Health In Physical Health Indicators

Attachment 1: Physical Health Indicators
H.

PBHCI
PHYSICAL HEALTH ITEMS

OMB No. 0930-0340
Expiration Date XX/XX/XXXX

[IF STAFF PREVIOUSLY INDICATED “NO DATA” WOULD BE SUBMITTED, GO TO SECTION I IF THIS IS
A REASSESMENT OR SECTION J IF THIS IS A DISCHARGE.]
1.

Health measurements:
a.
b.
c.
d.
e.
f.

Systolic blood pressure
Diastolic blood pressure
Weight
Height
Waist circumference
Breath CO - for smoking status

mmHg
mmHg
kg
cm
cm
ppm

2.

Did patient successfully fast for 8 hours prior to providing the blood sample?

3.

Blood test results (required only once a year):
a.

Date of blood draw:

|__|__| / |__|__| /|__|__|__|__|
MONTH DAY
YEAR

[FOR 3b AND 3c: ENTER ONE OR THE OTHER, NOT BOTH.]
b.
c.
d.
e.
f.
g.

Fasting plasma glucose
HgBA1c
Total Cholesterol
HDL Cholesterol
LDL Cholesterol
Triglycerides

mg/dL
%
mg/dL
mg/dL
mg/dL
mg/dL

[IF THIS IS A BASELINE, STOP HERE.]
[IF THIS IS A REASSESSMENT, GO TO SECTION I.]
[IF THIS IS A CLINICAL DISCHARGE, GO TO SECTION J.]

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. The OMB control
number for this project is 0930-0340. Public reporting burden for this collection of information is estimated
to average 5 minutes per respondent, per year, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance
Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.