Transcription of High Blood Pressure Questionnaire
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High Blood Pressure Questionnaire
H5825_MA_167_2009_v_01_BloodPressSurvey CMS Approved high Blood Pressure Questionnaire C C Name: Date Completed: Member #: Date of Birth: Thank you for taking the time to complete this Questionnaire . Your answers are important and will help us to meet your health care needs. This Questionnaire will take about 10 minutes to finish General Information 1. What is your address and best contact telephone number? _____ ( ) _____ (Address) (City, State, Zip code) (Phone number) 2. What is your primary language? Do you need an interpreter? Yes No Don t know 3. What is the name of the doctor or care provider you see most? _____ Clinic Name/Address: _____ Phone: ( ) _____ General Health Information 4.
H5825_MA_167_2009_v_01_BloodPressSurvey CMS Approved 06.16.2009 High Blood Pressure Questionnaire Additional Information 33. Would you like to participate in our high blood pressure educational
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