PRO-FORMA FOR HYPERTENSION SCREENING FROM INDIA

S. No:
* Name :
* Age:
* Address:
* Mobile No:
* Gender :
* Education status :
* Religion :
* Location :
* Economic Status :
* Family history :
If yes
Father :
Mother:
Both :
Siblings : Others :
* Habits :
* Occupation :
* Anthropometric details : Date:            
HT Cms :      
WT Kgs :       
BMI :            

Calculate BMI

Waist Cms :
BP systolic:
BP Diastolic:
* Hypertension If yes, Duration of HTN
* Treatment for HTN : If yes, treatment for HTN : Drug details:
* Date:
* Place: