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Ystradgynlais Group Practice Welcome. Croeso

Blood pressure review

Blood Pressure Review (2 readings)

Have you been asked by the practice to complete this online review? *

Yes

No

Who has requested your blood pressure readings? *

GP

Pharmacist

Other

Please specify: *

Section

Smoking

Do you smoke? *

Current smoker

Ex-smoker

Never smoked

Would you like to arrange an appointment for smoking cessation?

Yes

No

BMI

Height (in metres): *

ie. 1.75

Weight (in KG): *

ie. 60.6

BMI

Please note: BMI calculator is only for patients aged 18 and over.

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

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

Amount of different types of drink representing more than one unit of alcohol

How many units of alcohol do you drink a week?

Your Blood Pressure

Please submit 2 readings for both morning and evening (4 readings per day).

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

Please add any further comments here:

Confirmation *

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

Consent

Please tick box to consent to receive a SMS response from the nurse (if required).

If you are human, leave this field blank.

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