Valley Parish Nurse Ministry Blood Pressure Screening Tool
Categories for Blood Pressure Level in Adults* (18 and older)
Church:
Screener's Name :
Contact Phone:
Contact Email:
Date
Optimal **
Normal
High Normal
Stage 1
Stage 2
Stage 3
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 hypertension
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