De Pere Health Department Blood Pressure Data Sheet
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1DE PERE HEALTH DEPARTMENT
BLOOD PRESSURE DATA SHEET
Please Print
List all prescribed and over the counter medications
Last Name:______________________________________
you are presently taking including herbal supplements.
First Name:______________________________________
Address:________________________________________
Telephone:______________________________________
Sex: ____Male ____ Female
Race:
____ American Indian or Alaska Native
____Asian
Date Reviewed __________
__________
__________
____Black or African American
____Native Hawaiin or other Pacific Islander
RISK ASSESSMENT
____White
Smoke cigarettes? ____yes ____no
____Other
____Pks/day
Ethnicity:
Chewing Tobacco ____yes ____no
____Hispanic or Latino
Do you take female hormone pills? ____yes ____no
____Not Hispanic or Latino
Do you exercise 15-30 min. at least 3x/wk? ____yes____no
Do you limit the fat & cholesterol you eat? ____yes ____no
Birth Date:______________________________
Do you limit the salt in your diet? ____yes____no
HIGH BLOOD PRESSURE HISTORY
DISEASE HISTORY
Yes
No
Have you ever been told you have high blood pressure?
Heart Attack
____
____
____ yes
Heart Disease
____
____
____ no
Stroke
____
____
Diabetes
____
____
If yes, have you done or are you doing any of the following?
Overweight
____
____
____Medication
____Exercise
High Cholesterol
____
____
____Diet
____Stopped Smoking
____Stress Management
____Weight Loss
I am voluntarily participating in a blood pressure screening
____Salt Reduction
____Other
sponsored by the De Pere Health Department. I understand
this screening is not a substitute for an examination by
How long since your blood pressure was checked by a
my own physician. I also understand I am responsible for
physician, clinic or hospital?
any and all follow-up with my medical provider. I
____ Within 1 year
acknowledge I was given a copy of the De Pere Health
____1-3 years
Department's Notice of Privacy Practices explaining how
____More than 3 yrs or never
my health information is handled. I have been given an
opportunity to discuss my concerns and have any
Name of physician or clinic:__________________________
questions answered.
Signed____________________________ Date__________
RN Signature_______________________________Date_________________
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Parent category: Medical