Body and Blood Pressure Measures

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

P_Att15_BodyBloodPressMeasrForm_20180802

Body and Blood Pressure Measures Form

OMB: 0923-0061

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Attachment 15.

P ease Study

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ATSDR estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

Body and Blood Pressure Measures Form



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)









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

No referral


Elevated

120-129

or

<80

No referral


Hypertension (Stage 1)

130-139

or

80-89

See a physician within 2 months


Hypertension (Stage 2)

140

or

90

See a physician within 1 month


Hypertensive Crisis

­>180

or

>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)

3


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