Blood Pressure Self-Monitoring Program Interest Form

The Blood Pressure Self-Monitoring Program designed to support individuals living with high blood pressure (hypertension). This evidence-based program supports educating individuals on how to properly take and monitor their blood pressure on their own as well as explore lifestyle changes to support improvement in blood pressure readings.

This is a 4-month program that consists of monthly educational seminars and meetings with a Heart Healthy Ambassador.

Please note completing this form does not guarantee enrollment. A YMCA Care Coordinator will contact you to discuss the program, your goals and support getting you connected to the Blood Pressure Self-Monitoring Program.

Name*

First NameLast Name

Mobile Phone Number*

Area CodePhone Number

Are you okay with receiving text messages regarding your interest in this program? (Data messaging rates my apply)

YesNo

Email*

example@example.com

Date of Birth*

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Are you currently living with high blood pressure (hypertenstion)?

Yes, self-diagnosedYes, diagnosed by a medical professionalNo

Are you currently taking any medication to control your blood pressure?

YesNo

Do you regularly check and/or monitor your blood pressure?

YesNo

Do you currently own blood pressure monitoring equipment (e.g. a blood pressure cuff)?

YesNo

Are you a current member of the YMCA?

How did you hear of the Blood Pressure Self-Monitoring Program?