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