SHP_2013 360B
Your High Blood Pressure Visit –
What to Expect, What to Ask
Your Name: Your Relationship to the Child:
Are there specific concerns you want to discuss today? □ No □ Yes
Have there been any major changes in your family lately?
□ None □ Move □ Job Change □ Separation □ Divorce □ Death in the family □ New pet
□ Other? Describe:
General Health Information. Since Your Last Visit: Yes No Unsure
Have you or your child had any major illness and/or hospitalizations?
Have you or anyone in your family (or your child’s relatives) developed new any medical problems?
Are there any changes to your (or your child’s) medications?
Are your (or your child’s) immunizations (includes flu and pneumonia vaccines) current?
Do you or any adults who are around you (or your child) smoke (includes inside or outside the house)?
Have you (or your child) been seen in the emergency room in the last 6 months for high blood pressure?
□ No □ Yes 1-2 times □ Yes 3-4 times □ Yes 5-6 times □ Yes more than 6 times
Have you been hospitalized for High Blood Pressure in the last 12 months?
□ No □ Yes 1-2 times □ Yes 3-4 times □ Yes 5-6 times □ Yes more than 6 times
In the last 12 months have you talked with a doctor or health provider about any of the following High Blood
Pressure Symptoms?
□ Severe headaches □ Confusion □ Chest pain □ Blurred vision □ Nausea and vomiting
□ Pounding in chest, neck □ Feeling very tired □ Dizziness
Do you check your blood pressure?
□ No □ Yes, everyday □ Yes, weekly □ Yes, every other week □ Yes, monthly
Have you talked with a doctor or health provider about starting or stopping any medications?
Medication List: Medication Concerns:
No Yes Describe
Have you received referrals, tests, follow-up on tests results and/or other needed care promptly? □ No □ Yes
