Blood Pressure Self-Monitoring Program Interest Form
Name
*
First Name
Last Name
Mobile Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently living with high blood pressure (hypertenstion)?
Yes, self-diagnosed
Yes, diagnosed by a medical professional
No
Are you currently taking any medication to control your blood pressure?
Yes
No
Do you regularly check and/or monitor your blood pressure?
Yes
No
Do you currently own blood pressure monitoring equipment (e.g. a blood pressure cuff)?
Yes
No
Are you a current member of the YMCA?
Yes
No
How did you hear of the Blood Pressure Self-Monitoring Program?
Self (decided to on own)
Non-primary car health professional
Primary Care Provider/Office
Community-based organization/Community Healthcare Worker
YMCA Staff
Family or Friend
Employer or employer's wellness program
Insurance Company
Media (new, advertising or social media)
Submit
Should be Empty: