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)

Section

Smoking status

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

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
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2nd Morning Measurement
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1st Evening Measurement
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2nd Evening Measurement
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Day 2

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
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1st Evening Measurement
/
2nd Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

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

Morning Measurement
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Evening Measurement
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Home Blood Pressure Measurement (HBPM) - Your Overall Average
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