Blood Pressure Self-Monitoring Enrollment Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
Email
Call
Sex
Male
Female
Prefer not to answer
Date of Birth
-
Month
-
Day
Year
Date
Have you ever been diagnosed with high blood pressure/hypertension?
Yes
No
Are you currently taking prescription medication to control or manage your high blood pressure?
Yes
No
Were you diagnosed in the last 12 months with high blood pressure/hypertension?
Yes
No
Do you have a home blood pressure cuff?
Yes
No
How did you hear about the program?
Please Select
Current/former program participant?
Doctor or other Health Care Professional
Employer
Family/Friend/Word of Mouth
Health Insurance Company
Media/Marketing
Screening Event/Health Fair
Y Staff Member/Volunteer
A direct mailing/email communication
A poster, flyer, or event at the Y
The Y's website
Other
Not Reported
Are you a member of the Foothills Area YMCA?
Yes
No
Not Reported
Employer Name (if applicable)
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Prefer not to Answer
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Prefer Not to Answer
Other
What is you highest level of education
Please Select
Less than High School
High School or GED
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate
Professional Degree (MD,JD, DDS, etc.)
Prefer not to answer
Submit
Should be Empty: