Body and Blood Pressure Measures

Attachment 15.

P ease Study

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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)

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