This material was prepared by Healthcentric Advisors, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMS-SIP_BP-20190910-11 Last Rev. 11/26/19 1

Screening Form Self-Measured Blood Pressure Monitoring to Improve Uncontrolled Hypertension

The SMBP Program is free! We will not bill your insurance.

The answers you give for these questions will help us to determine

your eligibility for the SMBP Project. This information will stay private.

Your Name: ___________________________________________________________

Your Home Address: ____________________________________ Apt #___________

City/Town: _________________________ State: _____ Zip Code: __________-_____

Your Home Telephone #: __________________ Your Cell Phone #_______________

The following determines your technical access to submit your BP readings.

My cell phone is a smartphone? Yes No Make & Model: ___________ Unsure

Is less than 3 years old: Yes No Unsure

Touch-screen? Yes No Unsure

Bluetooth-enabled: Yes No Unsure

Has a data plan or has access to WiFi: Yes No Unsure

Uses: Android OS (6.0+) Apple iOS (10.0+) Unsure

Your Doctor’s Name (who manages your BP): ________________________________

City/Town of Office: ________________ Doctor’s Phone #_______________________

1. What health insurance do you have?

You can check more than one:

Medicare (often a red, white and blue card, also known as “Original Medicare”)

Medicare Advantage (like an HMO or PPO)

Medicaid

Private insurance

I don’t have insurance

I don’t know

2. Gender:

Identify as Male

Identify as Female

Other ________________ _____________________

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3. What is your ethnicity?

Check only one:

Hispanic or Latino/a

Not Hispanic or Latino/a

Unknown

4. What is your race?

Check all that apply:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other (tell us):______________________________________________

5. What is your birth date? Month / Day / Year: __ __ / __ __ / __ __ __ __

6. When did your doctor tell you that you have high blood pressure?

Check only one:

Less than one year ago

Less than two years ago

Less than three years ago

Less than four years ago

Four or more years ago

I don’t know / I don’t remember

7. Which health condition(s) do you have?

Check all that apply:

High cholesterol

High blood pressure

Arthritis

Heart disease

Lung Disease

Kidney disease

Eye disease (such as retinopathy)

Alzheimer’s or Related Dementia

Cancer or Cancer Survivor

Chronic Pain

Depression or Anxiety Disorders

Diabetes

Multiple Sclerosis

Osteoporosis (Low Bone Density)

Stroke

Atrial fibrillation (A-fib)

Other chronic condition (tell us): ______________________

None

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8. What is your most recent:

BP_______/_______ Ht. ____’____” Wt. ________lbs. BMI _________

9. What is the goal reading for your blood pressure? ________/________

I don’t know

10. What are you doing to help control your BP? (check all that apply)

Medication(s) - Name/dose/frequency ____________________________________________________

Anticoagulant medication

Antihypertensive medication

Dietary changes

Physical activity

Stop smoking/vaping

Stress reduction

I don’t know, not sure

11. How often do you miss medication doses? ______________________________

12. Do you take your medications as prescribed?

Yes No

13. Do you need assistance to afford your medications?

Yes No

14. Do you smoke or vape?

Yes

No (Skip to Question 16)

15. If you do smoke or vape, are you trying to quit?

Yes

No

16. What is the highest grade you completed?

Check only one:

8th grade or less

Some high school

High school diploma

Some college or technical school

College degree

Graduate or professional degree

17. How did you hear about this program? (Check all that apply)

Senior center My doctor A friend or family member The building where I live

Church Poster, flier, or mailing Ad in magazine or newspaper Other (tell us what): _____________

18. Have you ever taken a course or class in how to manage your high blood pressure or chronic disease(s)?

Yes No

I don’t know or not sure

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19. Do you speak a language other than English at home?

Yes No

20. If yes, what is that language? (Check all that apply)

Spanish

Chinese

Korean

Portuguese

Other language (tell us): ________________________

21. During the past year did you provide regular care or assistance to a friend or family member who has a long-term health problem or disability?

Yes No

22. Are your activities limited in any way because of physical, mental, or emotional problems?

Yes No

23. How many people live in your household (including yourself)? _____________

24. Do you have access to purchase fresh groceries weekly?

Yes No

25. What is the combined annual (yearly) income of your household?

Under $12,000

$12,000 - $16,999

$17,000 - $20,999

$21,000 - $25,999

$26,000 - $29,999

$30,000 - $34,999

$35,000 - $38,999

$39,000 - $42,999

$43,000 - $49,999

$50,000 - $74,999

$75,000 – $99,999

$100,000 and over

Refused to answer

Internal Use Only: ___________________ Unique ID#: ______________________________________________________________________

Site where screened: __________________________________________________________________________________________

Date/Time:__________________________________________________________________________

Screener: ____________________________________________________________________________________________________