Form Mo 580-3116 - Wisewoman Blood Pressure Medical Follow-Up Form - Missouri Department Of Health And Senior Services

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
Bureau of Cancer and Chronic Disease Control
WISEWOMAN Blood Pressure Medical Follow-Up Form
Face-to-Face in Office Only
DATE
PROVIDER NAME
DATE OF BIRTH (MM/DD/YYYY)
SOCIAL SECURITY NUMBER
NAME: LAST
FIRST
MIDDLE INITIAL
A. FIRST BLOOD PRESSURE MEDICAL FOLLOW-UP
st
nd
BP 1
BP 2
______/______
______/______
Is the client compliant with medications/treatment plan?
Yes
No
Client Refused
Were blood pressure (BP) medications prescribed or adjusted?
Yes
No
Client Refused
Can the client obtain BP medications?
Yes
No
Client Refused
Was the client given access to resources or were resources given?
Yes
No
Client Refused
Is the client self-monitoring BP?
Yes
No
Treatment Plan:
Information Discussed with Client:
Health Coaching
Healthy Eating
Physical Activity
Blood Pressure Medical Follow-Up
Sodium Reduction
Smoking Cessation
Client Refused
Weight Loss
B. SECOND BLOOD PRESSURE MEDICAL FOLLOW-UP
st
nd
BP 1
BP 2
______/______
______/______
Is the client compliant with medications/treatment plan?
Yes
No
Client Refused
Were BP medications prescribed or adjusted?
Yes
No
Client Refused
Can the client obtain BP medications?
Yes
No
Client Refused
Was the client given access to resources or were resources given?
Yes
No
Client Refused
Is the client self-monitoring BP?
Yes
No
Treatment Plan:
Information Discussed with Client:
Health Coaching
Healthy Eating
Physical Activity
Blood Pressure Medical Follow-Up
Sodium Reduction
Smoking Cessation
Client Refused
Weight Loss
C. THIRD BLOOD PRESSURE MEDICAL FOLLOW-UP
st
nd
BP 1
BP 2
______/______
______/______
Is the client compliant with medications/treatment plan?
Yes
No
Client Refused
Were BP medications prescribed or adjusted?
Yes
No
Client Refused
Can the client obtain BP medications?
Yes
No
Client Refused
Was the client given access to resources or were resources given?
Yes
No
Client Refused
Is the client self-monitoring BP?
Yes
No
Treatment Plan:
Information Discussed with Client:
Health Coaching
Healthy Eating
Physical Activity
Client Refused
Sodium Reduction
Smoking Cessation
Weight Loss
Comments:
MO 580-3116 (4-16)

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