Blood Pressure Questionnaire
*
Name
*
Gender
Male
Female
*
Martial Status
*
Age
*
Province
--Select--
Sindh
Punjab
Balochistan
KPK
Gilgit-Baltistan
*
City
*
Area
*
Hypertension
Yes
No
*
Duration
*
On Medications
Yes
No
*
Diabetese Mellitus
Yes
No
*
Smoking Status
--Select--
Never
Former
Current
*
Dietary Habits
--Select--
Vegetables
Meat Ghee
Oil
*
Fruits
Yes
No
*
Salt Intake
--Select--
High
Moderate
Low
*
Blood Pressure
--Systolic--
<120
120-129
130-139
140-149
150-159
160>
--Diastolic--
<80
80-89
90-99
100-110
>110
