Form Section H Section H Section H

8. PBHCI

PHYSICAL HEALTH ITEMS

Questions H1-H3 OMB No. 0930-0285

Expiration Date xx/xx/xxxx

bmarcogliese

2016-11-29 16:42:48

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Accepted set by bmarcogliese

1. Health measurements:

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.	Fasting plasma glucose HgBA1c	mg/dL %
d. e.	Total Cholesterol HDL Cholesterol	mg/dL mg/dL
f. g.	LDL Cholesterol Triglycerides	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 reporting burden for this collection of information is estimated to be approximately 5

additional minutes for the individual entering data into SPARS for an average of 200 clients per site at all 60 PBHCI sites. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. 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 control number for this project is 0930-0285.