Virginia Healthy Heart Ambassador Blood Pressure Self-Monitoring Program: Enrollment Form
General InstructionsGoal: This form collects necessary contact, demographic, and health information to tailor your 4-month cardiovascular wellness journey. Privacy: Your information is handled in accordance with the Virginia Department of Health confidentiality policies and is transmitted securely. Accuracy: Please provide the most current information to ensure your coach can reach you for wellness check-ins
Contact and Demographics
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Prefer Not to Answer
Preferred Contact Method
*
Phone
Email
Text
Other
Other Preferred Contact
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary Care Provider Information
Does the participant have a Primary Care Physician/Provider?
*
Yes
No
Name of Primary Care Physician/Provider
Primary Care Physician/Provider Location (City/Town/County)
Can the participant communicate with the provider through a personal computer portal?
*
Yes
No
Don’t Know
Health History and Measurements
Diagnosed with high blood pressure / hypertension?
*
Yes
No
Currently taking prescription medication to manage high blood pressure?
*
Yes
No
Diagnosed in the last 12 months with high blood pressure / hypertension?
*
Yes
No
Diagnosed with lymphedema?
*
Yes
No
Has a home blood pressure monitor and cuff?
*
Yes
No
Ethnicity, Race, Education, and Readiness
Are you Hispanic, Latino(a), or of Spanish origin?
*
Yes
No
Prefer Not to Answer
Race
White or Caucasian
Black or African-American
Native American or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Middle Eastern or North African
Some other race
Race - Other (specify)
Highest level of education
*
Less than high school
High school diploma or equivalency (GED)
Associate’s Degree
Bachelor’s Degree
Master’s Degree
Doctorate
Professional Degree
Highest level of education - Other (specify)
Baseline Data to be Completed by Program Facilitator
Leave this section blank: Your Program Facilitator or Coach will complete the Baseline Data. Initial Measurement: They will record your starting blood pressure and assess your "Readiness to Participate" on a scale of 1–10 during your first in-person or virtual meeting
Readiness to Participate
Please Select
10
9
8
7
6
5
4
3
2
1
Initial BP Measurement - Systolic BP
Initial BP Measurement - Diastolic BP
Initial BP Measurement - Arm
Right
Left
Measurement taken by (Name)
HIPAA form received
Yes
Informed Consent form received
Yes
Authorization for Release of Information to Health Care Provider form received
Yes
No
Program fee paid ($)
Program fee - N/A
N/A
Submit
Should be Empty: