Hypertension Evaluation Worksheet 

 

Name ____________________________________________D.O.B.___________________

 _

Age _______ Weight _________ Height _________  Blood pressure(s)_________________

Smoking History ___________________________  Smokes now? _____Non-smoker _____

Personal Medical History ____________________________________________________

Family Medical History _______________________________________________________

__________________________________________________________________________

                                    Age                              Health                           Cause of Death

Father ____________________________________________________________________

Mother ____________________________________________________________________

Brother(s) _________________________________________________________________

Sisters(s) __________________________________________________________________

Coronary Risk Factors ________________________________________________________

__________________________________________________________________________

        Blood Pressure

#1 Date _____/_____/_____  Reading ____/____  Location ___________________

#2 Date _____/_____/_____  Reading ____/____  Location ___________________

#3 Date _____/_____/_____  Reading ____/____  Location ___________________

EKG (resting) ____________ GXT (if indicated) ____________________________

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Labs:  Date __________    Fasting glucose ________   Total cholesterol _______  

LDL _______   HDL _______    VLDL _____________Triglycerides ________

Creatinine _______ Potassium _______ 2°pp glucose _______(if indicated)

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Medications usage:

Rx: _________________ Dosage  __________  Frequency __________

Rx: _________________ Dosage  __________  Frequency __________

Rx: _________________ Dosage  __________  Frequency __________

Presence/history/absence of adverse side effects: ________________________________

________________________________________________________________________

Signature ________________________________________________________MD/DO

Printed name & address ______________________________________________________

___________________________________________________________________________

Phone & fax # _______________________________________________________________

Date: __________________________________