Body and Blood Pressure Measures Form

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Multi-site Study
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.
*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)