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 provide a minimum of 14 readings (7 morning readings and 7 evening readings).

Blood Pressure Review (2 readings)

If you are human, leave this field blank.

Section

About You

Smoking status

Smoker

Never smoked

Ex-smoker

How many per day do you smoke?

When did you give up smoking?

Your Blood Pressure

Please submit 2 readings for both morning and evening.

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. Averages do not include day 1.

Morning Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Evening Measurement

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Overall Average Blood Pressure

This is automatically calculated for internal use only. Averages do not include day 1.

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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