Body and Blood Pressure Measures Form

Attachment 13.

Form Approved

OMB No. 0923-0063

Exp. Date 05/31/2023

Multi-site Study

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 (0923-0063).

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.

Check One	BP Category	Systolic BP (mm Hg)		Diastolic BP (mm Hg)	Action*
	Normal	<120	and	<80	You should still continue to have your regular appointments and check-ups with your doctor
	Elevated	120-129	and	<80	You should still continue to have your regular appointments and check-ups with your doctor
	Hypertension Stage 1	130-139	or	80-89	You should call your doctor and ask for an appointment
	Hypertension Stage 2	≥ 140	or	≥ 90	You should call your doctor and ask for an appointment
	Hypertensive Crisis	­>180	and	>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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