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    Blood Pressure Screening Form 0907

    Uploaded by

    Meganne Walsh
    This document is a blood pressure screening enrollment and monitoring form for adults 18 years and older at Saint Mary's Church in Amarillo. It collects personal information such as name, contact details, medical history, lifestyle factors and blood pressure readings over multiple dates. Participants consent to have their blood pressure taken and agree to follow up with their physician if elevated readings are found. The form also provides codes to categorize blood pressure levels, lists recommended lifestyle modifications, records the client's response and any follow up actions taken.

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    Download as PDF, TXT or read online from Scribd

    Blood Pressure Screening Form 0907

    Uploaded by

    Meganne Walsh
    758 views2 pages
    This document is a blood pressure screening enrollment and monitoring form for adults 18 years and older at Saint Mary's Church in Amarillo. It collects personal information such as name, contact details, medical history, lifestyle factors and blood pressure readings over multiple dates. Participants consent to have their blood pressure taken and agree to follow up with their physician if elevated readings are found. The form also provides codes to categorize blood pressure levels, lists recommended lifestyle modifications, records the client's response and any follow up actions taken.

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    This document is a blood pressure screening enrollment and monitoring form for adults 18 years and older at Saint Mary's Church in Amarillo. It collects personal information such as name, contact details, medical history, lifestyle factors and blood pressure readings over multiple dates. Participants consent to have their blood pressure taken and agree to follow up with their physician if elevated readings are found. The form also provides codes to categorize blood pressure levels, lists recommended lifestyle modifications, records the client's response and any follow up actions taken.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    758 views2 pages

    Blood Pressure Screening Form 0907

    Uploaded by

    Meganne Walsh
    This document is a blood pressure screening enrollment and monitoring form for adults 18 years and older at Saint Mary's Church in Amarillo. It collects personal information such as name, contact details, medical history, lifestyle factors and blood pressure readings over multiple dates. Participants consent to have their blood pressure taken and agree to follow up with their physician if elevated readings are found. The form also provides codes to categorize blood pressure levels, lists recommended lifestyle modifications, records the client's response and any follow up actions taken.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Saint Mary's, Amarillo Church Name ______________________________________________

    Blood Pressure Screening Enrollment and Monitoring Form for Adults 18 years and older.
    Name _____________________________________ Home Phone _______________ Cell Phone _______________

    Address ___________________________________ City __________________ State ________ Zip _____________ I consent to have my blood pressure taken as a screening procedure and will assume responsibility for follow-up with my physician if elevated. Signature ___________________________________________________ Date ____/____/_____
    (Please complete the form below prior to your screening.)

    Race: (Check one) ________ Caucasian ________ African American ________ Native American ________ Hispanic/Latino ________ Asian ________ Other Marital Status: ___ Married ___ Single Sex: ___ Male ___ Female

    Do you exercise 30 minutes per day? Check one: _________ _________ _________ _________ 4+ days/week 3 days/week 1-2 days/week Seldom/Never

    Have you been diagnosed with: Prehypertension: ____ Yes ____ No Hypertension: ____ Yes ____ No Target Blood Pressure/Date: (from MD)

    History of current health problems (Check all that apply.) Self: ___________ Kidney Disease ___________ Diabetes ___________ Heart Disease ___________ Stroke ___________ High Cholesterol

    How many servings of fruit per day do you eat? _____________

    __________________________ List current prescribed and over-the-counter medications taken: ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ Family: ___________ Kidney Disease ___________ Diabetes ___________ Heart Disease ___________ Stroke ___________ High Cholesterol

    Age: __________ Date of Birth: ___/___/______ Weight: ______________ Height: ______________

    How many servings of vegetables per day do you eat? ______

    Do you smoke? Yes __________ No _________

    Continued

    Name _________________________________________________

    Date (s)

    BP

    Repeat BP after 5 minutes

    BP Code (Table 1)

    Lifestyle Changes Taught (Table 2)

    Client Response (Table 3)

    Follow-up Done (Table 4)

    Comments/Screener Initials

    TABLE 1: BP Codes
    BP Code A B C D Category Normal Prehypertension Hypertension,Stage 1 Hypertension, Stage 2 SBP mmHg / DBP mmHg <120 and <80 80-89 90-99 >100

    TABLE 2: Lifestyle Modifications & Recommendations


    Lifestyle Modifications 1. Weight Reduction 2. DASH Eating Plan 120-139 or 140-159 or >160 or Lifestyle Recommendations Maintain normal body weight Adopt a diet rich in fruits, vegetables, and lowfat dairy products with reduced content of saturated and total fat. Reduce dietary sodium intake Gradually increase regular physical activity Men: limit to 2 or less drinks per day Women & lighter weight person: limit to 1 or less per day Quit, Does not smoke

    3. Dietary Sodium Reduction 4. Physical Activity 5. Moderation of alcohol consumption

    *Key: SBP = systolic blood pressure (upper number) DBP = diastolic blood pressure (lower number)

    Use the higher number SBP or DBP to determine classification.

    TABLE 3: Client Response


    1. 2. 3. 4. 5. 6. 7. 8. 9. Plans lifestyle changes Attempting lifestyle changes Making lifestyle changes Has upcoming appointment with MD Plans to see MD Does not intend to see MD Saw MD - tests normal Saw MD - no treatment change Saw MD - medication prescribed or changed 6. Smoking Champs Center for Healthy Aging, Ministries, Programs & Services 13271 Millard Avenue Omaha, Nebraska 68137 Tel: (402) 895-2224 Website: www.champsonline.info Email: champs@crossandheart.org

    TABLE 4: Follow-up Done


    1. 2. 3. Referred to Doctor or Clinic Personal contact /date Written follow-up sent/date
    Champs is funded by a grant from the Alegent Health Community Benefit Trust

    Adapted from Nebraska Health Ministry and JNC 7 Recommendations

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