YMCA Blood Pressure Self Monitoring Assessment

Take Action to Improve Your Heart Health

YMCA of Southern Nevada is offering an evidence based wellness program to help you develop a self monitoring routine, including tips to maintain cardiovascular health and nutrition education.

Please complete this short form and we will contact you to get started.
How old are you?*

Less than 40 years (0 points)40 – 49 years (1 point)50 – 59 years (2 points)60 years or older (3 points)
Are you a man or a woman?*

Male (1 point)Female (0 points)
Have you ever been diagnosed with diabetes, kidney disease, or sleep apnea?*

Yes (1 point)No (0 points)
Do you have a mother, father, sister or brother with heart disease?*

Yes (1 point)No (0 points)
Have you been diagnosed with high blood pressure?*

Yes (1 point)No (0 points)
Are you physically active?*

Yes (0 points)No (1 point)
On the chart below, find your height and weight range. Then scroll to the bottom of the chart to see the number of points. How many points does the chart say for your height and weight?*

0 points – My weight is lower that what is listed for my height1 point2 point3 point
Your Score
Complete the form below, and we will contact you about our program, which provides participants with a coach and group support to help you on your cardiovascular health journey.
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
What is your race? *

Black or African AmericanWhite/CaucasianAmerican Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific Islander
Do you have any prior experiences with cardiac arrest or stroke within the past 12 months?*

I have had a cardiac arrestI have had a strokeI have not had a cardiac arrest nor strokeI do not know
What is your preferred YMCA of Southern Nevada Branch?

Centennial HillsDurango HillsHeinrichSky ViewNo preference
What type of insurance do you have?

I don’t have insuranceMedicareMedicaidPrivate insurance
How did you hear about YMCA of Southern Nevada’s wellness programs?

Social mediaWebsiteTextWord of mouthOther
Are you currently a member of the YMCA?

YesNo
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