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 2 readings in the morning and 2 readings in the evening for 7 days.

For advice on how to take your Blood Pressure at home please visit: youtu.be/BritishHeartFoundation

Please ensure you check your Spam/Junk email folder for any replies. An appointment/reply will be sent back to you via an email.

Blood Pressure Diary and Review

Blood Pressure Diary and Review

Have you been asked by the practice to complete this online review? *
Who has requested your blood pressure readings? *

eg. 1.75
eg. 60.6

Smoking

Smoking status *
How many cigarettes did you smoke in a day?
How many cigarettes do you smoke in a day?
Would you like to arrange an appointment for smoking cessation?

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

Blood Pressure

Patient Instructions

  • In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes.
  • Then sit in a chair comfortably upright with your arm supported on a table beside you, with both feet on the ground.
  • Put the cuff on your upper arm (5cm above your elbow) resting on the table, the cuff should be roughly at the level of your heart.
  • Press the on/start button on the BP monitor and take two readings at least 1 minute apart.
  • Record the readings below with your pulse rate and any comments.
  • Repeat that evening & for a total of 7 days using alternate arms.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Day 1

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

Evening Measurements
/
/

Day 2

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

Evening Measurements
/
/

Day 3

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

Evening Measurements
/
/

Day 4

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

Evening Measurements
/
/

Day 5

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

Evening Measurements
/
/

Day 6

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

Evening Measurements
/
/

Day 7

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

Evening Measurements
/
/

Average Blood Pressure

This is automatically calculated for internal use only. Average does not include day 1.

Morning Measurements

/
Evening Measurements
/
*