Process - Physician - Fraser Health Authority

Client name: _______________________________METABOLIC MONITORING FORMMENTAL HEALTH AND SUBSTANCE USE (MHSU)PHN: _____________________________________DOB (dd/mm/yy): ________________ Age: _______Gender: Male Female Unknown/undifferen.Psychiatrist: _______________________________MHXX104076B Rev: Apr. 11/11Page: 1 of 3VULNERABILITIES – To be completed at baseline / first screeningHigh riskLow riskPersonal medical history Diabetes No or unknown historyHigh cholesterolHypertensionHeart diseaseOther: _________________________No or unknown historyNo or unknown historyNo or unknown historyNo or unknown historyFamily medical history Diabetes No or unknown history(First-degree relative – i.e.,High cholesterolNo or unknown historymother/father/sibling)HypertensionNo or unknown historyHeart diseaseOther: _________________________Ethnicity Aboriginal Arab(Origin/descent should be basis forAfricanCaucasianclassification, not country of residence)AsianHispanicSouth AsianTobacco use Current user Non-userPhysical activityNutrition(STC = Starting the Conversation tool)Quit < 7 days agoQuit ≥ 7 days ago< 30 min / day or 150 min / week or noappreciable exercise (sedentary)No or unknown historyNo or unknown history≥ 30 min / dayHigher STC score (8 – 16) Lower STC score (0 - 8)ADDITIONAL VULNERABILTIES FOR CVD AND DIABETESMale genderPrint Shop #261926Cardiovasculardisease riskFamily history of premature coronary heart disease (first degree relative - male 45 years) Special populations (e.g., low socioeconomic status, major mental disorders, treatmentwith protease inhibitor, glucocoricoids, or psychotropic medication treatment) History of impaired glucose tolerance or impaired fasting glucose (associatedwith insulin resistance)Presence of complications associated with diabetesHistory of vascular disease (coronary, cerebrovascular or peripheral)Female: History of gestational diabetes or delivery of macrosomic infantFemale: Polycystic ovary syndrome