Body and Blood Pressure Measures Form

Attachment 13.

M ulti-site Study

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Body and Blood Pressure Measures Form

Adult Study ID No. |_________________| OR Child Study ID No. |_________________|

Date: |__|__|/|__|__|/|__|__| Time: |__|__|:|__|__| □ AM □ PM

PHYSICAL MEASUREMENTS

Height: |__|’ |__|__|. |__|” (Nearest ½”) Modification to Procedure?

□ Yes □ No

Reason:_______________________________________

_____________________________________________

Weight: |__|__|__| lbs. Modification to Procedure?

□ Yes □ No

Reason:_______________________________________

BMI: |__|__|. |__| kg/m²

Abdominal Girth: |__|__|__|” (inches)

Hip: |__|__|__| (inches)

Waist: |__|__|__| (inches)

BLOOD PRESSURE

Blood Pressure:

1. |__|__|__|/|__|__|__| (mm Hg) Modification to Procedure?

□ Yes □ No

2. |__|__|__|/|__|__|__| (mm Hg) Reason:_______________________________________

_____________________________________________

3. |__|__|__|/|__|__|__| (mm Hg)

This chart reflects blood pressure categories defined by the American Heart Association.

Check One	BP Category	Systolic BP (mm Hg)		Diastolic BP (mm Hg)	Action*
	Normal	<120	and	<80	You should still continue to have your regular appointments and check-ups with your doctor
	Elevated	120-129	and	<80	You should still continue to have your regular appointments and check-ups with your doctor
	Hypertension Stage 1	130-139	or	80-89	You should call your doctor and ask for an appointment
	Hypertension Stage 2	≥ 140	or	≥ 90	You should call your doctor and ask for an appointment
	Hypertensive Crisis	­>180	and	>120	See physician immediately

*Defined by American Heart Association

Classification of BP in Adults Aged 18 Years or Older.

* If systolic and diastolic categories are different, the shorter recommended time for recheck and referral takes precedence. If two or three repeated systolic or diastolic measurements are abnormal but fall in different categories, determine the appropriate category based on their average.

If referral made, to whom (mark one):

□ No referral made

□ Emergency Room (Phone: xxx-xxx-xxxx)

□ Participant’s Provider (Name: |_________________|; Phone: |__|__|__|-|__|__|__|-|__|__|__|__|)

□ Referral 3 (Phone: xxx-xxx-xxxx)

□ Referral 4 (Phone: xxx-xxx-xxxx)

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