Contact us
Tel: 0800 BANKMED (0800 226 5633) • Private Bag X2, Rivonia 2128 • www.bankmed.co.za
Personal Health Assessment (PHA) & HIV/AIDS Counselling & Testing (HCT)
The Bankmed Personal Health Assessment (PHA) and HIV/AIDS Counselling & Testing (HCT) are health screening tools designed to
identify any health risks you may have, to allow for proactive intervention. Kindly take your form to your Healthcare Professional
for capturing of the information below and further follow up of any risks identified.
Member details
D D M M Y Y Y Y
Membership number Dependant code Date
Contact number Age Gender: Female Male
First name
Surname
Identity number
Wellness screening
Please answer the following questions in the applicable column yes or no:
1. Do you smoke? Yes No
2. Do you suffer from Diabetes? Yes No
3. Do you have any chronic condition/s for which you are
Yes No
on medication?
4. If yes, kindly indicate below:
Asthma Cardiac Disease Depression
Diabetes High Cholesterol Hypertension Other
To be filled in by an accredited General Practitioner, Pharmacist, Biokineticist or Nurse
5.Current weight (with normal clothing) to the nearest kg
6. Height (without shoes) m
7. Body Mass Index (weight/height2 – kg/m2)
8. Blood pressure – Systolic mmHg
– Diastolic mmHg
9. Total cholesterol mmol/l
HDL mmol/l
LDL mmol/l
Triglycerides mmol/l
10. Random blood glucose mmol/l
11. Waist circumference cm
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Reference
BMI <24.9
Total Cholesterol <5.0
HDL >1.2
LDL <3.0
Triglycerides <1.7
Random glucose <7.8
Blood pressure <130/80
Waist Circumference
Women <80 cm
Men <94 cm
HIV Test Results Maternity information
What is your known HIV status? Currently pregnant Yes No
HIV negative HIV positive I don't know Estimated date D D M M Y Y Y Y
of delivery
Screening test: Negative Positive Inconclusive Not done
Confirmatory test Negative Positive Inconclusive Not done
First test ever? Yes No
First test in 12 months? Yes No
HIV self-reported risk assessment High Medium Low
TB Screening
Does your patient currently D D M M Y Y Y Y
Yes No If yes: date TB treatment started:
have TB?
If no: does your patient have the following:
Persistent cough for more than two weeks? Yes No
Chest pain or difficulty breathing? Yes No
Fever for more than two weeks? Yes No
Unexplained significant weight loss? Yes No
Excessive night sweats? Yes No
Presence of blood when coughing up phlegm? Yes No
TB contact in the patient’s household? Yes No
Sputum sample taken? Yes No
Patient referred to State clinic Yes No
1. I acknowledge that by giving my consent on this form, I am giving my consent to the provisions outlined below which relate to the
Bankmed Medical Scheme (“Bankmed”):
1.1. Personal Health Assessment (“PHA”) health screening tool and programme; and
1.2. HIV counselling, testing and disease management programme (“HIV programme”), (collectively, the “Programmes”).
2. I acknowledge that Bankmed, its administrators and/or managed healthcare organisation (collectively, the Bankmed Parties) will administer
the Programme, including the information which I have provided in this document.
3. Although the Programmes are designed to:
3.1. Identify certain health risks I may have and enrol me in the PHA programme; and/or
3.2. Assess my medical risk and to enrol me on the HIV programme, any treatment or medicines prescribed (including antiretroviral
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treatment, if applicable), as well as the general management of my healthcare, is the sole responsibility of my healthcare provider(s),
in consultation with me.
4. The Bankmed Parties are accordingly not liable for any claims by me or my dependants arising from any treatment or medicines prescribed,
or arising from the implementation of the Programmes, save insofar as provided in the Bankmed rules.
5. I understand that no personal information provided by me in terms of the Programmes, including health status and treatment-related
information, (“Personal Information”), will be disclosed to third parties (including my employer), other than Bankmed Parties and my
healthcare provider(s), without my consent.
6. Consent for storing and accessing of my HIV results and HIV related information:
We are committed to protecting your right to privacy and your personal information, especially related to your HIV status.
I hereby consent to the storing and accessing of my HIV results and HIV related information as follows:
To store my HIV results and HIV related information collected in the Clinical Data Repository (CDR). The CDR is a central store of clinical data
housed outside of the various product house environments. It aims to provide one view of a member’s latest medical history.
Yes No
7. Whilst the Bankmed Parties will use their best endeavours to uphold the confidentiality of all my Personal Information, the Bankmed
Parties will not be liable for any claims by me or my dependants arising from any unauthorised disclosure of my Personal Information to a
third party.
8. I can terminate my participation in the Programmes at any time with immediate effect on notice to a Bankmed Party, but understand that,
in terms of the HIV programme, all benefits that I enjoyed under that programme shall immediately cease.
9. I acknowledge that should I not comply with the HIV programme protocols or prescribed treatment, Bankmed, in its sole discretion, may
elect to exercise its rights and limit any benefits to the prescribed minimum benefits, always subject to the applicable legislation and the
Bankmed rules.
10. I understand that telephone calls will be recorded for internal quality assurance purposes and, in respect of the HIV Programme,
recorded calls will not be shared outside of the HIV programme unit.
11. The Bankmed parties will use the information to allocate the appropriate points to Balance, the Bankmed Wellness Programme.
12. I understand and acknowledge that “consent”, for purposes of this document means my informed consent, in other words:
12.1. I have read and understood the contents of this document.
12.2. I understand and acknowledge the nature of the Personal Information that will be made available to and disclosed, used, processed
and retained by the Bankmed Parties and my healthcare provider(s), as set out in this consent.
12.3. I understand and acknowledge the purpose for which the Personal Information relating to me will be made available to, and
disclosed, used, processed and retained by the Bankmed Parties and my healthcare provider(s), as set out in this consent.
12.4. I have the legal capacity to give my informed consent, in other words, I am over the age of 18 years old and am able to fully
understand and make decisions about my own healthcare
Counselled, agree to be tested and participate in the HIVCare
Counselled, not tested Counselled and agree to be tested
Programme
D D M M Y Y Y Y
Date
Signature
Bankmed Medical Scheme is a registered medical scheme and regulated by the Council for Medical Schemes (CMS). The CMS contact details are as follows:
E-mail: [email protected] | Customer Care Centre: 0861 123 267 | Website: www.medicalschemes.co.za BEMPHA001
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