NCD Patient Interview Form
Please complete this form during the clinical interview to record key information for patients with non-communicable diseases.
Patient Full Name
*
First Name
Last Name
Date of Interview
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age
*
Gender
*
Male
Female
Other
Main Condition/Diagnosis
*
Please Select
Diabetes Mellitus
Hypertension
Chronic Respiratory Disease
Cardiovascular Disease
Cancer
Other (please specify)
Current Symptoms
Fatigue
Shortness of Breath
Pain
Cough
Swelling
Other
Current Management (medications, treatments, etc.)
Lifestyle Factors
Smoker
Alcohol Use
Sedentary Lifestyle
Unhealthy Diet
Regular Exercise
Other
Follow-up Needs
Routine follow-up
Specialist referral
Laboratory tests
Medication adjustment
Other
Additional Notes
Submit
Should be Empty: