YMCA's BLOOD PRESSURE SELF-MONITORING PROGRAM
PARTICIPANT ENROLLMENT FORM
Are you referring a patient from a health care facility?
*
Yes
No
Name of Referral Provider
Patient Identifier (ex: WIC1, 29203-1)
Name of Person Completing this Form
First Name
Last Name
In-person or Virtual Attendance Preferred
*
In-Person
Virtual only
Virtual or In-Person
In-Person Branch Preference
Please Select
Downtown
Ponds
Select ALL TIMES you are available to participate in Weekly Office Hours that are 10-15 minutes increments
Rows
Monday
Tuesday
Wednesday
Thursday
Friday
9-10 AM
10-11 AM
11 AM - 12 PM
1-2 PM
2-3 PM
3-4 PM
4-5 PM
5-6 PM
6-7 PM
Patient/Participant Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text
Does this patient need a Spanish speaking Healthy Heart Ambassador?
*
Yes
No
Gender
*
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 blood pressure monitor at home?
*
Yes
No
How did you hear about this program?
*
Y staff member or volunteer
A poster, flyer or event at the Y
A friend or family member or word of mouth
The Y's web site
A doctor or other health care professional
Media TV, web, radio, print, etc
A direct mailing/e-mail communication
YMCA Community Health Screening Event
Other
Reason for Referral
*
Uncontrolled Hypertension
Uncontrolled Diet
Needs to implement exercise
Other
Are you a member of the YMCA?
*
Yes
No
What is your race (select all that apply)
*
White or Caucasian
Native Hawaiian or Other Pacific Islander
Black or African American
American Indian or Alaska Native
Asian
Prefer not to answer
Other
What is your highest level of education
*
Less than high school
Master's degree
High school diploma or equivalency (GED)
Doctorate
Associate degree (junior college)
Professional MD, JD, DDS, etc
Bachelor's degree
Other
What is your highest level of education
Less than high school
Master's degree
High school diploma or equivalency (GED)
Doctorate
Associate degree (junior college)
Professional MD, JD, DDS, etc
Bachelor's degree
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YMCA STAFF only
HHA Patient Assigned To
Please Select
Brae
Malika
Branch Enrolled At
Please Select
Downtown
Ponds
Configurable list
*
Patient is: Contacted, Waiting on Medical Clearance, Cleared to Participate, Waitlisted, Enrolled, Declined, Completed
Contacted
Waiting on Medical Clearance
Cleared to Participate
Waitlisted
Enrolled
Declined
Withdrew
Completed
Submit
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