1. Oneida Community Health Nursing Department Disease Screening Form- updated 02/28/12 MLM Have you been screened for diabetes or high blood pressure beforeYESYESNO Have you been diagnosed with diabetes or pre-diabetes?YESYESNO Have you been diagnosed with high blood pressure?YESYESNO Are you pregnant?YESYESNO Have you had anything to eat or drink within the last 8 hours?YESYESNO Have you received a copy of the Oneida Community Health Center Privacy Practice Notice and signed a Notice of Acknowledgement at the Oneida Community Health Center? YESYESNO Participant’s NameDate of Birth Gender Male/ Female AddressPO BoxCountyEmail address CityStateZip Code Telephone Number () RaceAmerican Indian/Alaska NativeEthnicity Native Hawaiian/ other Pacific IslanderWhiteHispanic/ Non Hispanic Black or African AmericanAsian Name of PhysicianClinic Name Blood pressure: Right/ left arm Adult/ large cuff I agree to voluntarily participate in this disease screening activity. I understand that this may involve a brief written test looking for risk factors associated with diabetes and/ or hypertension. I understand that if the results of any of the testing fall outside the health care providers’ criteria, the results will be forwarded to my physician. No other individual or agency can use my results for any other purpose without my express written permission. I also understand that the screening exam is not a substitute for an examination of my own physician and that false reading are possible in a general screening. I hereby release the health care providers from all responsibility in connection with screening and understand that I am responsible for any and all follow-up with my medical provider. I have read, understood and accept the conditions stated in the above paragraph. Participant Signature X Date Signed American Heart Association Elevated Reading: 120/80 or above Emergency = 180/110 or above Additional Comments: The above individual was seen today at a Public Health screening. Their results fell outside of our range of normal, and thus we are providing their information to you. They have been informed of their need to follow-up with you for continued evaluation and care. If you have questions or concerns, please feel free to contact the Oneida Community Health Nursing Department at (920) 869-2711. Screened By: X Date Signed Blood Sugar: (Reference range 70-100 mg/dl.) Fasting/ Random American Diabetes Association Guidelines for physician evaluation (No previous diagnosis of diabetes) Elevated reading: **Complete risk assessment** Fasting = greater than 100 Random = greater than 140 Emergency = 300 or above Hemoglobin A1C: (Reference range is 4.0-6.0%) **Complete risk assessment** American Diabetes Association Guidelines for physician evaluation Elevated reading: Pre-diabetes = 5.7% - 6.4% Diabetes = 6.5% Emergency = > 12% Risk test and screening exam worksheets Oneida Tribe of Indians of Wisconsin * The clinical measures listed on these documents were used by the programs over the past 10 years and were current at their time of use. However, these example documents are not intended to serve as current clinical guidelines. Programs using these documents will need to ensure the clinical measures are current for their intended use.