BPSM Self Referral Form

West Cook YMCA Blood Pressure Self-Monitoring Program Referral Form
To qualify, participants must be at least 18 years of age, diagnosed with hypertension or currently taking antihypertensive medication, not have experienced a recent cardiac event, not have atrial fibrillation or other arrhythmias, and not be at risk for lymphedema.

This form is HIPAA Compliant.
Participant Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Sex (at birth)*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Height*
Weight*
lbs
BMI*
kg/m
Have you been diagnosed with hypertension?*

YesNo
Are you currently taking antihypertensive medication?*

YesNo
Have you had a recent cardiac event in the last 12 months?*

YesNo
Do you have atrial fibrillation or other arrhythmias?*

YesNo
Are you at risk for lymphedema?*

YesNo
Today's Date*

MonthDayYear
Date
Should be Empty:

West Cook YMCA Blood Pressure Self-Monitoring Program Referral Form