Blood Pressure Review

If you have been advised by the practice to submit your blood pressure readings on a regular basis please use this form and complete two readings in the morning and two readings in the afternoon. Thank you.

Blood Pressure Review (2 readings)

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About You

Full Name: *

Phone Number:

Smoking status

Smoker

Never smoked

Ex-smoker

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’ readings.

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.

Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Home Blood Pressure Measurement (HBPM) - Your Overall Average

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

I confirm that the information provided is accurate to the best of my knowledge

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About You

Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure

Hay Fever