Survey Proforma
Survey Proforma
Survey Proforma
Proforma
Demographics:
Nam
e
Designati
on
Address
Ag
e
Se M/
x F
Ban
k
Mobile No.
Email
Id
Questionnaire:
Past history of Hypertension: yes /no
Duration:
Treatment:
Symptom
0
1
2
3
4
5
6
7
8
Chest pain:
Breathlessness:
On Exertion
Extra
Ordinary(2)
Less
ordinary(1)
Ordinary(3)
Tiredness:
Palpitations:
Light or heavy
Head
Giddiness
MARK *ASTERIK IF BREATHLESSNESS ON LYING DOWN
9
than
10
Rest(
4)
If you experienced any of the above symptoms in the past or now DURING OR
AFTER WORK HOURS, please circle the number most appropriate to describe the
severity of the symptom. (0 being absence of the symptom entirely, and 10
being the most severe.)
TIME
HEART RATE:
beats/minute
DIASTOLIC
PRESSURE
MEAN
ARTERIAL
PRESSURE
PULSE
PRESSURE
SITTING
(SIGNATURE)
RESULTS:
TOTAL Surveyed
Normal Recordings
Prehypertension
Stage 1 HTN
Stage 2 HTN
Low Recordings
SYMPTOMATIC
ASYMPTOMATIC
MALE
FEMALE
Classification of Hypertension
Category
Blood Pressure, mm Hg
Normal
SBP 90-119 and 60-79
Prehypertension
SBP 120-139 or DBP 80-89
Stage 1 HTN
SBP 140-159 or DBP 90-99
Stage 2 HTN
SBP 160 or DBP 100
DBP = diastolic blood pressure; SBP = systolic blood pressure
ANALYSIS