Blood Pressure Self-Monitoring Program Enrollment Form

* indicates information required to complete intake

If you need assistance completing this form, please contact us at ymcabpsm@ymcasv.org.

Si necesita ayuda para completer este formulario, comuniquese con nosotros al ymcabpsm@ymcasv.org.

Name Name First Last
Birthdate Birthdate / MM / DD YYYY
Gender
Email

Confirm Email Address
Preferred Phone Preferred Phone - ### - ### ####
Address Address
Street Address City State / Province / Region Postal / Zip Code
Race
Ethnicity
Education
Referral Method
Name of Referring Clinic or Healthcare Provider (Optional)
Employer Name (Optional)
Are you a current YMCA of Silicon Valley Member?

Are you a current YMCA of Silicon Valley Member? Yes No
If Yes, select your home YMCA from the drop down menu below:
Which program location do you prefer?
PARTICIPANT QUALIFICATION

Please answer the following questions:
Please answer the following questions:	Yes	No
Have you ever been diagnosed with high blood pressure/hypertension?	Have you ever been diagnosed with high blood pressure/hypertension?Yes	Have you ever been diagnosed with high blood pressure/hypertension?No
Were you diagnosed in the last 12 months with high blood pressure/hypertension?	Were you diagnosed in the last 12 months with high blood pressure/hypertension?Yes	Were you diagnosed in the last 12 months with high blood pressure/hypertension?No
Are you currently taking prescription medication to control or manage your high blood pressure?	Are you currently taking prescription medication to control or manage your high blood pressure?Yes	Are you currently taking prescription medication to control or manage your high blood pressure?No
Have you experienced a cardiac event within the last 12 months?	Have you experienced a cardiac event within the last 12 months?Yes	Have you experienced a cardiac event within the last 12 months?No
Do you have atrial fibrillation?	Do you have atrial fibrillation?Yes	Do you have atrial fibrillation?No
Do you have other arrhythmias?	Do you have other arrhythmias?Yes	Do you have other arrhythmias?No
Are you at risk for lymphedema?	Are you at risk for lymphedema?Yes	Are you at risk for lymphedema?No
Do you have a home blood pressure cuff?	Do you have a home blood pressure cuff?Yes	Do you have a home blood pressure cuff?No

Blood Pressure Self-Monitoring Program Enrollment Form

Blood Pressure Self-Monitoring Program Enrollment Form

PARTICIPANT QUALIFICATION