Program Evaluation

Session*
Please select the session you are evaluating.
Demographic Information
Please complete this form only if you have been diagnosed with high blood pressure. If you attended as a significant other, thank you for coming but do not complete this form.
Gender*
- Male
- Female
- Other
Age*
- 20-21
- 22-34
- 35-49
- 50-64
- 65+
Race*
- Non-Hispanic Origin
- Hispanic by Race
Race – Non-Hispanic Origin*
- White
- Black
- Asian/PI
- American Indian
- Other/Unknown
Race – Hispanic by Race*
- White
- Black
- Other/Unknown

I am a Medicaid recipient and am interested in using a self-monitoring blood pressure device, yet have not been able to get one. Someone from the Windsor Health Department will contact you.
- Yes
Phone*
Please enter your phone number so that the Windsor Health Department may contact you.
Are you a Windsor resident?*
- Yes
- No
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code

Demographic Information