First Name
Last Name
Age
Gender		M	F
Environment		Rural	Urban
1	Your attending physician has diagnosed you with arterial hypertension. Are you aware of this diagnosis?	Yes
		No
2	What was the highest value of blood pressure you ever had measured?
3	Have you ever been diagnosed with diabetes?	Yes	What treatment are you following?	Diet
				Antidiabetic oral drugs
				Insulin
		No
4	Have you ever been diagnosed with dyslipidemia? (increased levels of fat in your blood—cholesterol or triglycerides?	Yes
		No
5	Are you a smoker?	Yes	How many cigarettes a day?
			For how many years?
		No
6	Is there a history of early deaths (under 55–65 years) because of heart attack, stroke or sudden death in your family?	Yes
		No
7	Let’s go back to blood pressure. Are you aware of the consequences of untreated high blood pressure?	Yes	Can you name at least one?
		No
8	What treatment are you following at home?
9	Over the course of a month, how often do you forget to take your medication?	Never
		1–3 times a month
		4–7 times a month
		Over 7 times a month
10	Do you strictly follow a low-sodium diet, which is specific for patients suffering from high blood pressure?	Never
		Sometimes
		Often
		Always
11	Presently, when you monitor your blood pressure values at home, what are the values?
12	Is your family supportive in maintaining the diet and following the treatment for your condition?	Yes
		No
		It is not necessary
13	For how long do you think you will have to follow the treatment for high blood pressure?
14	Apart from your general practitioner, is there any other doctor who periodically assesses your high blood pressure?	Yes	What is their medical specialty?
		No
15	How many times a year do you visit a specialist physician?	Once a year
		Twice a year
		≥Three times a year
16	What investigations have been done by the specialist physicians who is assessing your blood pressure?	Electrocardiogram
		Cardiac ultrasound
		Doppler ultrasound of carotid and cerebral arteries
		Abdominal ultrasound
		Blood and urine tests
		Fundoscopy Exam
		Others
17	Do you suffer from other diseases, other than the conditions mentioned above (high blood pressure, dyslipidemia, diabetes)?
18	If you were to rate your general state today from 1 to 10, how would you rate it?