Blood Pressure Self Monitoring Enrollment Form

How to Enroll

Please complete the form below and a member of our Community Health Team will reach out to you to finish program enrollment. Alternatively, you can call the Welcome Center at 607-257-0101 or visit the Welcome Center to begin the enrollment process.
First Name
Last Name
Gender
 
Date of Birth
Race
 
Are you Hispanic, Latino(a), or of Spanish origin?
 
What is your highest level of education?
Address
Address 2
City
State
Zip
Phone Number
Email Address
What is your current membership status at the Ithaca YMCA?
Please list the full name and phone number of your emergency contact person.

Program-Specific Questions
Have you ever been diagnosed with high blood pressure/hypertension?
 
Are you currently taking prescription medication to control or manage your high blood pressure?
 
Have you had a cardiac event in the last 12 months?
 
Do you currently have atrial fibrillation or other arrhythmias?
 
Have you been told that you are at risk for lymphedema?
 
How did you hear about this program?
 
Physician's Name
Physician's Practice

For more information, contact Gunnar Madison, Health and Wellness Director, at gmadison@ithacaymca.com.