High Blood Pressure Assessment Form Step 1 of 2 50% First Name* Last Name* Email* Date MM slash DD slash YYYY Do you monitor your blood pressure as prescribed by your physician? Yes No No MD order Last BP reading Are you on a low salt or low caffeine diet? Yes No No MD order How many times per week have you been engaging in exercise? 0 1-2 3-4 5 or more Are you currently using any tobacco products? Yes No How many drinks of a alcoholic beverage do you have in a typical week? None 1 or less 2 or more Do you take any supplements? Potassium Calcium Magnesium Other If other, please list them here. Have you had a Fasting Lipid profile drawn at least once over the last 12 months? Yes No Lipid Profile Date Total Cholesterol LDL HDL Triglycerides Have you had any changes in your Blood Pressure medications? Yes No If yes, please list changesHave you achieved your current Blood Pressure goal? Yes No What goal do you want to achieve for your Blood Pressure before your next follow-up?**All medical information will be kept confidential in accordance with HIPAA Thank you for taking the time to complete the questionnaire. We wish you continued success on your Road To Wellness!PhoneThis field is for validation purposes and should be left unchanged. Δ
