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| Did you know that a "normal" blood pressure for a child is different than for an adult?: |
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| If your child is age 3 or over, has he or she had their blood pressure taken in the past 6 months?: |
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| Does your child routinely receive blood pressure checks from their physician?: |
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| If your child is age 3 or over has he or she required a visit to an emergency room or after hours clinic in the past 12 months?: |
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| If yes, did your child have their blood pressure taken during that visit? (Either upon arrival with the triage nurse or during their time in the exam area?): |
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| As a parent, were you aware of the importance of having your child's blood pressure taken before learning of the National Pediatric Blood Pressure Awareness Foundation?: |
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| How likely are to ask your child's physician to take their blood pressure during the next visit?: |
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Has your child had any health problems in the past? (Ex. Heart, Kidney, Asthma, Ears, ADD, ADHD, Autism, etc.) If so, please list all that apply.:
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Does your child routinely take any medications? If so, please list the condition it is treating.:
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| Child's age.: |
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Comments or any additional information you would like to provide:
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| Would you consider supporting the NPBPAF in their endeavors?: |
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