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

Smoking status
Would you like help to give up smoking?

For more information and help to give up smoking, please visit: www.quitwithhelp.co.uk

Are you currently prescribed blood pressure medications?
Please select from the following:

Your Blood Pressure

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

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

/
Evening Measurement
/
*