RKC Trust- May Measurement Month- Online Participant Questionnaire (WEEK 1) Survey

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1. Name of City/Town/Village: (Required.)

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2. Where is your screening site? (Required.)

Hospital/Clinic

Pharmacy

Public area (indoors)

Public area (outdoors)

Home

Workplace

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3. Date of measurement (Required.)

DD/MM/YYYY format

Date

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4. How old are you (in years)? (Required.)

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5. What is your sex? (Required.)

Male

Female

Other

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6. When did you last have your blood pressure (BP) measured? (Required.)

Never

Over 12 months ago

Within the last 12 months

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7. Have you ever been diagnosed with high BP by a health professional (except in pregnancy)? (Required.)

Yes

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8. Are you taking any BP medication? (Required.)

Yes

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9. If you answered YES to Q8, how many different types of BP medication are you taking?

I dont't know

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10. Are you currently taking a statin/cholesterol
medication? (Required.)

Yes

Don't know

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11. Are you currently taking Aspirin? (Required.)

Yes

Don’t know

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12. If female, are you pregnant?

Yes

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13. Do you use tobacco/nicotine (including
chewing tobacco, cigars, and pipes)? (Required.)

Yes

No-but I did in the past

Never

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14. Do you vape (e-cigarettes)? (Required.)

Yes

No– but I did in the past

Never

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15. Do you consume alcohol? (Required.)

Never/rarely

1-3 times per month

1-6 times per week

Daily

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16. Have you ever experienced or been diagnosed
as having the following (please tick approprate boxes)?

Heart attack

Stroke

Heart failure

Irregular heartbeat

Diabetes

Kidney failure

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17. Do you have a parent or sibling with diabetes? (Required.)

Yes

Don't know

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18. Do you take part in at least 150 mins of moderate exercise
(brisk walking) or 75 mins of more vigorous exercise per week? (Required.)

Yes

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19. What type of diet do you eat? (Required.)

Non vegetarian

Vegetarian

Pescetarian (fish but no other meat)

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20. How many years of education do you have? (Required.)

1-6 years

7-12 years

over 12 years

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21. Weight (Please mention "estimate" adjacent to weight, if weight is not measured but just estimated) (Required.)

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22. Height (Please mention "estimate" adjacent to height, if height is not measured but just estimated)

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23. What is your waist size? (Please mention "estimate" adjacent to waist size, if waist is not measured but just estimated)

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24. What is the manufacturer of the BP machine being used? (Required.)

OMRON

Other

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25. Please enter your blood pressure in this format "Systolic blood pressure (SBP)/ Diastolic blood pressure (DBP)" (Required.)

1st measurement

2nd measurement

3rd measurement

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26. Please enter your heart rate (pulse rate) (Required.)

1st measurement

2nd measurement

3rd measurement

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27. Personal details (Optional)

Name

Phone number

RKC Trust- May Measurement Month- Online Participant Questionnaire (WEEK 1)

Question Title

* 1. Name of City/Town/Village: (Required.)

Question Title

* 2. Where is your screening site? (Required.)

Question Title

* 3. Date of measurement (Required.)

Question Title

* 4. How old are you (in years)? (Required.)

Question Title

* 5. What is your sex? (Required.)

Question Title

* 6. When did you last have your blood pressure (BP) measured? (Required.)

Question Title

* 7. Have you ever been diagnosed with high BP by a health professional (except in pregnancy)? (Required.)

Question Title

* 8. Are you taking any BP medication? (Required.)

Question Title

* 9. If you answered YES to Q8, how many different types of BP medication are you taking?

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* 10. Are you currently taking a statin/cholesterolmedication? (Required.)

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* 11. Are you currently taking Aspirin? (Required.)

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* 12. If female, are you pregnant?

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* 13. Do you use tobacco/nicotine (includingchewing tobacco, cigars, and pipes)? (Required.)

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* 14. Do you vape (e-cigarettes)? (Required.)

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* 15. Do you consume alcohol? (Required.)

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* 16. Have you ever experienced or been diagnosedas having the following (please tick approprate boxes)?

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* 17. Do you have a parent or sibling with diabetes? (Required.)

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* 18. Do you take part in at least 150 mins of moderate exercise(brisk walking) or 75 mins of more vigorous exercise per week? (Required.)

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* 19. What type of diet do you eat? (Required.)

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* 20. How many years of education do you have? (Required.)

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* 21. Weight (Please mention "estimate" adjacent to weight, if weight is not measured but just estimated) (Required.)

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* 22. Height (Please mention "estimate" adjacent to height, if height is not measured but just estimated)

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* 23. What is your waist size? (Please mention "estimate" adjacent to waist size, if waist is not measured but just estimated)

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* 24. What is the manufacturer of the BP machine being used? (Required.)

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* 25. Please enter your blood pressure in this format "Systolic blood pressure (SBP)/ Diastolic blood pressure (DBP)" (Required.)

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* 26. Please enter your heart rate (pulse rate) (Required.)

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* 27. Personal details (Optional)

1. Name of City/Town/Village: (Required.)

2. Where is your screening site? (Required.)

3. Date of measurement (Required.)

4. How old are you (in years)? (Required.)

5. What is your sex? (Required.)

6. When did you last have your blood pressure (BP) measured? (Required.)

7. Have you ever been diagnosed with high BP by a health professional (except in pregnancy)? (Required.)

8. Are you taking any BP medication? (Required.)

9. If you answered YES to Q8, how many different types of BP medication are you taking?

10. Are you currently taking a statin/cholesterol
medication? (Required.)

11. Are you currently taking Aspirin? (Required.)

12. If female, are you pregnant?

13. Do you use tobacco/nicotine (including
chewing tobacco, cigars, and pipes)? (Required.)

14. Do you vape (e-cigarettes)? (Required.)

15. Do you consume alcohol? (Required.)

16. Have you ever experienced or been diagnosed
as having the following (please tick approprate boxes)?

17. Do you have a parent or sibling with diabetes? (Required.)

18. Do you take part in at least 150 mins of moderate exercise
(brisk walking) or 75 mins of more vigorous exercise per week? (Required.)

19. What type of diet do you eat? (Required.)

20. How many years of education do you have? (Required.)

21. Weight (Please mention "estimate" adjacent to weight, if weight is not measured but just estimated) (Required.)

22. Height (Please mention "estimate" adjacent to height, if height is not measured but just estimated)

23. What is your waist size? (Please mention "estimate" adjacent to waist size, if waist is not measured but just estimated)

24. What is the manufacturer of the BP machine being used? (Required.)

25. Please enter your blood pressure in this format "Systolic blood pressure (SBP)/ Diastolic blood pressure (DBP)" (Required.)

26. Please enter your heart rate (pulse rate) (Required.)

27. Personal details (Optional)