BLOOD PRESSURE SELF-MONITORING
REGISTRATION FORM
Location
Delaware
Gahanna
Grove City
Hilliard
Pickaway
Ward
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Preferred Contact Method
*
Phone
Email
Gender
*
Male
Female
Prefer not to answer
Date of Birth
*
-
Month
-
Day
Year
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Have you ever been diagnosed with high blood pressure/hypertension?
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Yes
No
Are you currently taking prescription medication to control ormanage your high blood pressure?
*
Yes
No
Were you diagnosed in the last 12 months with high bloodpressure/hypertension?
*
Yes
No
Do you have a home blood pressure cuff?
*
Yes
No
How did you hear about this program?
*
Y staff member or volunteer
A friend or family member or word of mouth
A doctor or other health care professional
A direct mailing/e-mail communication
A poster, flyer or event at the Y
The Y’s web site
Media (TV, web, radio, print, etc.)
Other
Are you a member of the Y?
*
Yes
No
Are you Hispanic, Latino(a), or Spanish origin?
*
Yes
No
Prefer not to answer
What is your race:
*
White or Caucasian
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Prefer not to answer
Other
What is your highest level of education:
*
Less than high school
High school diploma or equivalency (GED)
Associate degree (junior college)
Bachelor’s degree
Master’s degree
Doctorate
Professional (MD, JD, DDS, etc.)
Prefer not to answer
Other
Submit
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