Form 1 SBP-Sitting Blood Pressure

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minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing
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OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Sitting Blood Pressure
FORM CODE: SBP
VERSION: 1, 1/7/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION

/

0a. Completion Date:
Month

/
Day

0b. Staff ID:
Year

Instructions: Enter results as measured. If measure is unobtainable, use the CDART Notelog window to code the
option as it applies.

A. Arm measurements
1. Arm used for sitting blood pressure measurement (choose one):
Right (preferred) ....................................................... 1
Left ........................................................................... 2
Other {note log} ........................................................ 3
2. Arm circumference (cm)

..............................................................................................

3. Cuff size: (arm circumference in brackets)
Small {17-22 cm, CS19}................................................................... 1
Adult {22-32 cm, CR19} ................................................................... 2
Large {32-42 cm, CL19} ................................................................... 3
X Large {42-50 cm, CX19} ............................................................... 4
4. Time of measurement (24-hr. format): ..................................................................
H

:
H : M

M

B. Average blood pressure / pulse rate
5. Systolic ............................................................................................................................
6. Diastolic ...........................................................................................................................
7. Pulse:

.....................................................................................................................

SBP-Sitting Blood Pressure_1-7-14.doc

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FORM CODE: SBP
VERSION: 1, 1/7/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

C. First blood pressure / pulse rate
8. Systolic ............................................................................................................................
9. Diastolic ...........................................................................................................................
10. Pulse:

.....................................................................................................................

D. Second blood pressure / pulse rate
11. Systolic ..........................................................................................................................
12. Diastolic .........................................................................................................................
13. Pulse:

.....................................................................................................................

E. Third blood pressure / pulse rate
14. Systolic ..........................................................................................................................
15. Diastolic .........................................................................................................................
16. Pulse:

.....................................................................................................................

SBP-Sitting Blood Pressure_1-7-14.doc

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