Form 1 ETS Control Your Blood Pressure

Control Your Blood Pressure Pre-survey
Introduction
EmPOWERED to Serve: Control Your Blood Pressure PRE-Survey
Please answer the questions below before you begin the Control Your Blood
Pressure experience.
The survey should take less than 1 minute to complete. Your answers are completely
confidential and will only be used to improve future EmPowered to Serve trainings and
education.
Survey Questions
1. Please enter the first two letters of your birth month.

For example, if you were born in November, enter ‘NO’.
_____________________________
2. Please enter the last three digits of your cell phone number.

For example, if your phone number is 214-763-9805, enter ‘805’.
_____________________________
3. In which of the following geographic regions do you currently live?
a. Central Valley/Kern County, CA
b. Las Vegas, NV
c. Orlando, FL
d. Charlotte, NC
e. Indianapolis, IN
f. Central Ohio, OH
g. Houston, TX
h. Philadelphia, PA
4. Which gender do you most identify with?
a. Male
b. Female
c. Non-binary
d. Prefer to self-describe: _______________
e. Prefer not to answer
5. Are you of Hispanic, Latino/a, or Spanish origin?
a. Yes
b. No
c. Prefer not to answer

6. What is your race? Please select all that apply.
a. Asian or Pacific Islander
b. Black or African American
c. American Indian or Alaskan Native
d. White or Caucasian
e. Other, please specify: ___________
f. Prefer not to answer
7. What is your age range?
a. 18-29
b. 30-44
c. 45-59
d. 60-69
e. 70-79
f. 80 or older
g. Prefer not to answer
8. What is the highest level of education you have completed?
a. Less than high school
b. Some high school
c. High school graduate or equivalent
d. Associate degree (such as AA, AS)
e. Bachelor’s degree (such as BA, BS)
f. Graduate degree (such as MBA, MS, MD, PhD)
g. Prefer not to answer
9. Do you currently know your blood pressure numbers?
a. Yes
b. No
10. The cutoff for a healthy blood pressure is anything below which of the following?
a. 100/60
b. 120/80
c. 130/90
d. 150/110
11. What is one potential consequence of high blood pressure?
a. Heart attack
b. Stroke
c. All of the above
d. None of the above

12. Please select the level that best represents your current confidence that you can do
the following:
Not at all
confident
Make lifestyle
changes to help
manage my blood
pressure
Monitor my blood
pressure at home

A little
confident

Somewhat
confident

Mostly
confident

Totally
confident

Not
applicable

o

o

o

o

o

o

o

o

o

o

o

o

Thank you for taking this survey. Your response has been recorded. We hope you enjoy
the EmPowered to Serve module.
Do not forget to take the post-survey after you finish the training!

Control Your Blood Pressure Post-survey
Introduction
EmPOWERED to Serve: Control Your Blood Pressure POST-Survey
Please answer the questions below after you complete the Control Your Blood
Pressure experience.
The survey should take less than 1 minute to complete. Your answers are completely
confidential and will only be used to improve future EmPowered to Serve trainings and
education.
Survey Questions
1. Please enter the first two letters of your birth month.

For example, if you were born in November, enter ‘NO’.
_____________________________
2. Please enter the last three digits of your cell phone number.

For example, if your phone number is 214-763-9805, enter ‘805’.
_____________________________
3. The cutoff for a healthy blood pressure is anything below which of the following?
a. 100/60
b. 120/80
c. 130/90
d. 150/110
4. What is one potential consequence of high blood pressure?
a. Cardiovascular disease
b. Stroke
c. All of the above
d. None of the above

5. After participating in the Control Your Blood Pressure experience, please select the
level that best represents your current confidence that you can do the following:
Not at all
confident
Make lifestyle
changes to help
manage my
blood pressure
Monitor my
blood pressure
at home

A little
confident

Somewhat
confident

Mostly
confident

Totally
confident

Not
applicable

o

o

o

o

o

o

o

o

o

o

o

o

6. Please rate the overall quality of your experience with Get Control Your BP . Select
your choice below.
Excellent

o

Above
average

Average

o

o

Below
average

o

Poor

o

Undecided

o

7. How likely are you to recommend the Control Your BP experience to a friend, family
member, or co-worker? Select your choice below:
Very likely

o

Likely

Neutral

o

o

Unlikely

o

Very
unlikely

o

Undecided

o

8. Is there anything you would like to learn more about that was not included in this
Control Your BP educational session? Please feel free to include any comments or
questions you have.
_______________________________________________________________________
We thank you for your time spent taking this survey.
Your response has been recorded.