Million Hearts Participant Clinical Recording Log
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1Million Hearts
Million Hearts
®
®
Participant Clinical
Participant Clinical
Recording Log
Recording Log
Participant #
Age _____
Participant #
Age _____
Gender (circle one): M F
Gender (circle one): M F
Race/ethnicity (circle one):
Race/ethnicity (circle one):
White/non-Hispanic Black/African American
White/non-Hispanic Black/African American
Latino/Hispanic Asian/Pacific Islander
Latino/Hispanic Asian/Pacific Islander
American Indian/Alaskan Native
Multiracial
Other
American Indian/Alaskan Native
Multiracial
Other
Smoking status (circle one): Current smoker
Smoking status (circle one): Current smoker
Social smoker Does not smoke
Social smoker Does not smoke
Fasting for >9 hours if applicable (circle one): Yes No N/A
Fasting for >9 hours if applicable (circle one): Yes No N/A
Blood pressure __________
Blood pressure __________
Body mass index __________
Body mass index __________
PSS-4 score __________
PSS-4 score __________
Total cholesterol __________
Total cholesterol __________
Counseling completed (circle one): Yes No
Counseling completed (circle one): Yes No
Referral to healthcare provider made (circle one): Yes No
Referral to healthcare provider made (circle one): Yes No
Million Hearts
Million Hearts
®
®
Participant Clinical
Participant Clinical
Recording Log
Recording Log
Age _____
Age _____
Participant #
Participant #
Gender (circle one): M F
Gender (circle one): M F
Race/ethnicity (circle one):
Race/ethnicity (circle one):
White/non-Hispanic Black/African American
White/non-Hispanic Black/African American
Latino/Hispanic Asian/Pacific Islander
Latino/Hispanic Asian/Pacific Islander
American Indian/Alaskan Native
Multiracial
Other
American Indian/Alaskan Native
Multiracial
Other
Smoking status (circle one): Current smoker
Smoking status (circle one): Current smoker
Social smoker Does not smoke
Social smoker Does not smoke
Fasting for >9 hours if applicable (circle one): Yes No N/A
Fasting for >9 hours if applicable (circle one): Yes No N/A
Blood pressure __________
Blood pressure __________
Body mass index __________
Body mass index __________
PSS-4 score __________
PSS-4 score __________
Total cholesterol __________
Total cholesterol __________
Counseling completed (circle one): Yes No
Counseling completed (circle one): Yes No
Referral to healthcare provider made (circle one): Yes No
Referral to healthcare provider made (circle one): Yes No
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Parent category: Medical