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* 1. Name of City/Town/Village:

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* 2. Where is your screening site?

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* 3. Date of measurement

Date

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* 4. How old are you (in years)?

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* 5. What is your sex?

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* 6. When did you last have your blood pressure (BP) measured?

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* 7. Have you ever been diagnosed with high BP by a health professional (except in pregnancy)?

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* 8. Are you taking any BP medication?

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* 9. If you answered YES to Q8, how many different types of BP medication are you taking?

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* 10. Are you currently taking a statin/cholesterol
medication?

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* 11. Are you currently taking Aspirin?

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* 12. If female, are you pregnant?

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* 13. Do you use tobacco/nicotine (including
chewing tobacco, cigars, and pipes)?

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* 14. Do you vape (e-cigarettes)?

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* 15. Do you consume alcohol?

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* 16. Have you ever experienced or been diagnosed
as having the following (please tick approprate boxes)?

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* 17. Do you have a parent or sibling with diabetes?

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* 18. Do you take part in at least 150 mins of moderate exercise
(brisk walking) or 75 mins of more vigorous exercise per week?

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* 19. What type of diet do you eat?

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* 20. How many years of education do you have?

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* 21. Weight (Please mention "estimate" adjacent to weight, if weight is not measured but just estimated)

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* 22. Height (Please mention "estimate" adjacent to height, if height is not measured but just estimated)

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* 23. What is your waist size? (Please mention "estimate" adjacent to waist size, if waist is not measured but just estimated)

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* 24. What is the manufacturer of the BP machine being used?

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* 25. Please enter your blood pressure in this format "Systolic blood pressure (SBP)/ Diastolic blood pressure (DBP)"

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* 26. Please enter your heart rate (pulse rate)

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* 27. Personal details (Optional)

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