Valley Parish Nurse Ministry Blood Pressure Screening Tool
Categories for Blood Pressure Level in Adults* (18 and older)

Church:

Screener's Name:

Phone Number:

 Email:

Date"
(mm/dd/yy)

Optimal **
< 120/<80

Normal
< 130/< 85

High Normal
130 - 139/
85 - 89

Stage 1
140 - 159/
90 - 99

Stage 2
160 - 179/
100 - 109

Stage 3
> or = to 180/
> or = to 110

Total Screened

Ages
0-18:
19-40:
41-65:
66-80:
81+:
0-18:
19-40:
41-65:
66-80:
81+:
0-18:
19-40:
41-65:
66-80:
81+:
0-18:
19-40:
41-65:
66-80:
81+:

Quarterly Total:

Recommendations:
Normal (<120/<80) : Learn more about hypeension
High Normal (<130/<85) : Learn more about prehypertension and consult Doctor
Stage 1 (140 - 159/90 - 99) : Check BP again and consult Doctor in 2 months
Stage 2 (160 - 179/100 - 109) : Consult Doctor within 1 month
Stage 3 (> or = to 180/> or = to 110) : Consult Dr. within 1 week or immediately if over 210 / 120

* For those not taking medicine for high blood pressure and not having a short term serious illness. These categories are from the National High Blood Pressure Education Program. www.nhlbi.nih.gov/hbp

** Optimal blood pressure with respect to heart disease risk is below 120/80 mm Hg. However, unusually low readings should be evaluated for clinical significance.

Please return this report to :
Valley Parish Nurse Ministry, 507 Seventh Ave., East Liverpool, OH 43920 or call results to 330-382-9440