HYPERTENSION ENCOUNTER FORM
HYPERTENSION ENCOUNTER form - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -continued Patient s name: ________________________________________ ______________________ Age: ______ Weight: _____ Height: _____ BMI (over): ______HISTORY OF PRESENT ILLNESS_________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ _______________________ Loud snoring, obesity, gasping and daytime sleepiness (sleep apnea) Headache, sweating and palpitations (pheochromocytoma)Major risk factors (check if present)Target-organ damage (check if present) HYPERTENSION Tobacco use Obesity (BMI 30 kg per m2) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or glomerular filtration rate < 60 mL per minute
HYPERTENSION ENCOUNTER FORM continued Encounter form developed by Mark H. Ebell, MD, MS. Copyright © 2004 American Academy of Family Physicians. Physicians may ...
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