Blood Pressure Form

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Participant ID: __ __ - __ __ - __ __ __ __
Participant Initials: __ __ __
Clinical Center: __ __
Site: __ __
Visit Number: __ __
CRF Date: __ __ /__ __ /__ __ __ __
RC ID: __ __ __ __
B
L
O
O
D
P
R
E
S
S
U
R
E
F
O
R
M
B
L
O
O
D
P
R
E
S
S
U
R
E
F
O
R
M
1. Date Blood Pressure taken:
__ __ / __ __/ __ __ __ __
MM
DD
YYYY
2. Time of day when seated Blood Pressure taken:
___ ___ : ___ ___ (military time)
3. Blood Pressure device number:
___ ___
4. Arm used:
Right
Left
1
2
5. Midpoint circumference of arm used:
___ ___ . ___ cm
6. Size of cuff (check one):
Child (< 24.0 cm)
1
Adult (24.0 to < 33.0 cm)
2
Large adult (33.0 to 41.0 cm)
3
Thigh (> 41.0 cm to 50.0 cm)
4
Thigh (> 50.0 cm)
5
7. Seated Pulse measurement (# in 30 seconds X 2):
___ ___ ___ beats/minute
H
H
a
a
v
v
e
e
p
p
a
a
r
r
t
t
i
i
c
c
i
i
p
p
a
a
n
n
t
t
r
r
e
e
m
m
a
a
i
i
n
n
s
s
e
e
a
a
t
t
e
e
d
d
f
f
o
o
r
r
5
5
m
m
i
i
n
n
u
u
t
t
e
e
s
s
.
.
8. Observed Pulse Obliteration Pressure:
___ ___ ___
9. Peak Inflation Level (Pulse Obliteration Pressure +30):
___ ___ ___
10. First seated Blood Pressure measure (Systolic/Diastolic):
___ ___ ___ / ___ __ ___ mmHg
W
a
i
t
f
o
r
3
0
s
e
c
o
n
d
s
.
W
a
i
t
f
o
r
3
0
s
e
c
o
n
d
s
.
11. Second seated Blood Pressure measure (Systolic/Diastolic):
___ ___ ___ / ___ __ ___ mmHg
W
W
a
a
i
i
t
t
f
f
o
o
r
r
3
3
0
0
s
s
e
e
c
c
o
o
n
n
d
d
s
s
.
.
12. Third seated Blood Pressure measure (Systolic/Diastolic):
___ ___ ___ / ___ __ ___ mmHg
H
a
v
e
p
a
r
t
i
c
i
p
a
n
t
s
t
a
n
d
f
o
r
2
m
i
n
u
t
e
s
.
H
a
v
e
p
a
r
t
i
c
i
p
a
n
t
s
t
a
n
d
f
o
r
2
m
i
n
u
t
e
s
.
13. Standing Pulse measurement (# in 30 seconds X 2):
___ ___ ___ beats/minute
14. Standing Blood Pressure (Systolic/Diastolic):
___ ___ ___ / ___ __ ___ mmHg
B
P
B
P
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