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Benin 2011

Survey form view entire document: text

NAME________
DATE_______
BLOOD PRESSURE___/_____
AVERAGE OF TWO MEASUREMENTS_____
SINGLE MEASUREMENT_______

READ THE DECLARATION BELOW, THEN CIRCLE:
1) Your blood pressure today is within the acceptable limit (systolic less than 130 and/or diastolic less than 85). We recommend that you see a doctor to redo the measurement of your blood pressure in the next two years. You need to show this sheet to the doctor.

2) Your blood pressure today is acceptable, but in the high range of the limit (systolic 130-139 and/or diastolic 85-89). We recommend that you see your doctor to redo the measurement of your blood pressure in the next year. You need to show this sheet to the doctor.

3) Your blood pressure today is above the acceptable range (systolic 140-159 and/or diastolic 90-99). We recommend that you consult your doctor to redo the measurement of your blood pressure in the next two months. You need to show this sheet to the doctor.

4) Your blood pressure today is moderately high (systolic 160-175 and/or diastolic 100-109). We recommend that you consult your doctor to redo the measurement of your blood pressure in the next 30 days. You need to show this sheet to the doctor.

5) Your blood pressure today is high (systolic 160-175 and/or diastolic 110-119). You must consult a doctor in the next week to retake your blood pressure. You need to show this sheet to the doctor.

6) Your blood pressure today is very high (systolic ? 210 and/or diastolic ? 120). You must consult a doctor or a health center immediately to retake your blood pressure. You need to show this sheet to the doctor.

Your blood pressure was measured by a trained individual. These measurements were conducted within a survey and thus does not represent a medical diagnosis. A proper interpretation of the measurements should be done by a doctor.

DATE_______
SIGNATURE________

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Lesotho 2009

Survey form view entire document: text

1211 USE THE TABLE BELOW TO DETERMINE THE CORRECT CODE TO RECORD ON THE BLOOD PRESSURE REPORT AND REFERRAL FORM.
CIRCLE THE ROW IN WHICH THE VALUE FOR THE SYSTOLIC BLOOD PRESSURE FROM Q1206 OR Q1210 IS FOUND.
THEN CIRCLE THE COLUMN IN WHICH THE VALUE FOR THE DIASTOLIC BLOOD FROM Q1206 OR Q1210 IS FOUND.
THE VALUE WHERE THE ROW AND COLUMN YOU HAVE CIRCLED INTERSECT IN THE TABLE WILL BE USED IN COMPLETING Q1212.

AVERAGE DIASTOLIC PRESSURE

Less than 84
85-89
90-99
100-109
110-119
greater than 120

AVERAGE SYSTOLIC PRESSURE

less than 130 1 2 3 4 5 6
130-139 2 2 3 4 5 6
140-159 3 3 3 4 5 6
160-179 4 4 4 4 5 6
180-209 5 5 5 5 5 6
greater than 210 6 6 6 6 6 6

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Lesotho 2014

Survey form view entire document: text

1211) USE THE TABLE BELOW TO DETERMINE THE CORRECT CODE TO RECORD ON THE BLOOD PRESSURE REPORT AND REFERRAL FORM. CIRCLE THE ROW IN WHICH THE VALUE FOR THE SYSTOLIC BLOOD PRESSURE FROM Q1206 OR Q1210 IS FOUND. CIRCLE THE COLUMN IN WHICH THE VALUE FOR THE DIASTOLIC BLOOD FROM Q1206 OR Q1210 IS FOUND. THE VALUE WHERE THE ROW AND COLUMN YOU HAVE CIRCLED INTERSECT IN THE TABLE WILL BE USED IN COMPLETING Q1212.

AVG. SYSTOLIC PRESSURE LESS THAN 120:

1 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
2 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
3 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE

AVG. SYSTOLIC PRESSURE LESS THAN 130:

2 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
2 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
3 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE

AVG. SYSTOLIC PRESSURE 130 - 139:

3 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
3 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
3 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE

AVG. SYSTOLIC PRESSURE 140 - 159:

4 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
4 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
4 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE

AVG. SYSTOLIC PRESSURE 160 - 179:

5 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
5 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
5 AVERAGE DIASTOLIC PRESSURE 85 - 89
5 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE GREAT THAN 110

AVG. SYSTOLIC PRESSURE GREATER THAN 180:

6 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
6 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
6 AVERAGE DIASTOLIC PRESSURE 85 - 89
6 AVERAGE DIASTOLIC PRESSURE 90 - 99
6 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE GREAT THAN 110

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