Blood Pressure Review

If you have been advised by the surgery to submit readings of your blood pressure please use this form.

For more information on blood pressure please see our Wellbeing Centre.

Blood Pressure Review (2 readings)

If you are human, leave this field blank.

Section

About You

Please provide the name of the person who requested your blood pressure readings (if known):

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.

For information on blood pressure and blood pressure measurements, please visit our Wellbeing Centre.

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

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

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