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.

Blood Pressure Review

Blood Pressure Review

If you are human, leave this field blank.

Please tell us why you are submitting this form: *

Doctor request

Nurse request

Part of annual health review

Following a raised blood pressure check in the reception at the surgery

Other

Name of doctor:

Name of nurse:

Please specify: *

Have you received a letter, text message or verbal invitation to complete this assessment? *

Yes

No

Smoking status

Smoker

Never smoked

Ex-smoker

How many per day do you smoke?

When did you give up smoking?

We would like to know about your level of breathlessness: *

I only get breathless with strenuous exercise

I get breathless when hurrying on level ground or up a slight hill

I walk slower than people my age when walking on level ground because of breathlessness or have to stop to catch my breath when walking on level ground

I stop for breath after walking 100 yards or every few minutes

I am too breathless too leave the house most of the time

Has this changed since your last review? *

Yes

No

Height:

Weight:

This is one unit of alcohol:

And each one of these, is more than one unit:

How many units of alcohol on average do you drink per week?

Your Blood Pressure

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

Day 1

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 2

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 3

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 4

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 5

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 6

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 7

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

If we need to contact you to discuss anything related to your form when is the best time to contact you? *

E.g. Monday AM/PM, Tuesday AM/PM

*

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

Submit