Blood Pressure Review

If you have been advised by the surgery to submit your blood pressure readings on a regular basis please use this form.

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Blood Pressure Review (2 readings)

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Section

Smoking status

Smoker

Never smoked

Ex-smoker

Weight:

How many per day do you smoke?

When did you give up smoking?

Your Blood Pressure

Please provide a minimum of one blood pressure reading, up to a maximum of seven days.

For each blood pressure recording provided, at least two consecutive measurements should be taken, at least one minute apart.

Day 1

Date:

Please use this date format: DD/MM/YYYY.

1st Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

1st Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 2

Date:

Please use this date format: DD/MM/YYYY.

1st Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

1st Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 3

Date:

Please use this date format: DD/MM/YYYY.

1st Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

1st Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 4

Date:

Please use this date format: DD/MM/YYYY.

1st Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

1st Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 5

Date:

Please use this date format: DD/MM/YYYY.

1st Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

1st Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 6

Date:

Please use this date format: DD/MM/YYYY.

1st Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

1st Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 7

Date:

Please use this date format: DD/MM/YYYY.

1st Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

1st Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

2nd Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only.

Please note: These averages do not include Day 1 readings.

Morning Measurement

Average morning systolic

Average morning diastolic

Average morning heart rate

Evening Measurement

Average evening systolic

Average evening diastolic

Average evening heart rate

Home Blood Pressure Measurement (HBPM) - Your Overall Average

Overall average systolic

Overall average diastolic

Overall average heart rate

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Section

Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure

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