|Description||Data to be Collected|
|All relevant chronic disease prevention and screening test results and values||cholesterol, fasting blood sugar, glycated hemoglobin, stool for blood, sigmoidoscopy, colonoscopy, pap, and mammogram|
|All relevant cancer surveillance results and values depending on personal history of cancer||breast - mammography, bone density; colorectal – colonoscopy, carcinoembryonic; antigen test, computerized axial tomography; prostate - prostate specific antigen test|
|Physical and vital information||
blood pressure, weight, height, and body mass index|
For patients randomized to the intervention group, the PP will take the BP, weight and height measurements during the visit with the patient. For patients randomized to wait-list control, these will be collected from their medical record (electronic or paper) at baseline and 12-month data collection time points.
|Referrals made or actions to be taken by the patient, PP, or primary care team in order to follow up on identified CCDPS items||Description of referrals and actions taken|