Blood Pressure Self-Monitoring Program: Participant Interest Form

Thank you for your interest in Health Promotion Council's Blood Pressure Self-Monitoring Program (BPSM)! Please complete the below form to express your interest in enrolling in this program. Once completed, a staff member from HPC will follow up with you to confirm your interest, provide more information about the program, and get you enrolled.

If you have any questions or concerns, you can contact the HPC team at programinfo@phmc.org

1.First Name

2.Last Name

3.Phone Number

4.Email Address

5.Home Zip Code

6.Have you ever been diagnosed with high blood pressure/hypertension?

Yes

7.If yes, were you diagnosed in the last 12 months with high blood pressure/hypertension?

Yes

8.Are you currently taking prescription medication to control or manage your blood pressure?

Yes

9.Have you had a heart attack or stroke in the last 12 months?

Yes

10.Have you previously been diagnosed with an arrhythmia or irregular heart beat?

Yes

11.Do you have a blood pressure cuff or monitor at home?

Yes

12.Programming will take place primarily in-person at PHMC's offices at 4601 Market Street, Philadelphia PA 19139. Are you willing and able to get to that location?

Yes

13.Programming will begin on Friday, May 1st with sessions and appointments in the early afternoon (12pm-3pm). Does that work for you?