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Required format:

Blood Pressure Tracker Demographics

Welcome to the Nebraska Department of Health and Human Services' Women's and Men's Health BLOOD PRESSURE TRACKER.

This tracker is an online tool that will help you log your blood pressure and monitor your blood pressure over a period of time so that you can know your numbers and share with your healthcare provider.

Measuring your blood pressure is the only way to know if you have high blood pressure. High blood pressure usually has no warning signs or symptoms and many people don't know that they have high blood pressure. Uncontrolled high blood pressure can cause hardening and thickening of the arteries, which can lead to a heart attack, stroke or other complications.

Here are the steps to use the tracker:
1) Enter your personal information into the system and at the end of the form please click "SUBMIT".

2) After you click on "SUBMIT" the Women's and Men's Health Program will assign you to a health coach. Once a health coach has been assigned you should receive an email. In that email is a link. Click on the link and you will be able to enter your blood pressure readings, date, time, and any notes that you think are important for your health coach to know.

3) You will receive an email every few days as a reminder to take your blood pressure and enter it into the system.

4) It is ideal to track your blood pressure at least 2 times a week for up to 3 months. This tracker system will send you reminders every few days for up to 3 months. You can opt out of reminders.

5) If you need additional information please contact the Nebraska Women's and Men's Health Program at 1-800-532-2227.

First Name:

* must provide value

Last Name:

* must provide value

Date of Birth

* must provide value

M-D-Y

Address:

* must provide value

City:

* must provide value

State:

* must provide value

Zip Code:

* must provide value

County:

* must provide value

Phone Number:

* must provide value

Phone Type:

* must provide value

Cell

Landline

Work

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Email Address:

* must provide value

Gender:

* must provide value

Male

Female

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Are you of Hispanic/Latina(o) origin?

* must provide value

Yes

Unknown

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What is your primary language:

* must provide value

English

Spanish

Other

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Other Language:

* must provide value

What race or ethnicity are you? (check all that apply)

* must provide value

American Indian/Alaska Native

Black/African American

Mexican American

White

Pacific Islander/Native Hawaiian

Unknown

Other

Tribe:

* must provide value

Other:

* must provide value

Do you currently see a medical provider for your blood pressure?

* must provide value

Yes

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Are you currently taking medications for your blood pressure?

* must provide value

Yes

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List of medications (you do not need to know dosages):

* must provide value

Expand

Date of last provider visit: (if known)

M-D-Y

Who referred you to this tracker?

* must provide value

Every Woman Matters/Women's & Men's Health Program

Local Health Department

Medical Clinic

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Name of Local Health Department:

* must provide value

Name of Medical Clinic:

* must provide value

Admin Group Email:

* must provide value

Thank you for filling out demographics information. After you click the 'Submit' button, your request will be sent to blood pressure tracking administration. Once they assign a health coach, you will receive your first email and link to begin blood pressure tracking.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.