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 (2 readings)

Section

About You

Smoking status

Guidance on taking blood pressure for home monitoring

  • Please read the following guidelines: Blood Pressure UK
  • Take at least 2 readings, leaving at least a minute between each. If the first and second reading are very different, take a further reading.
  • Do not round the readings up or down.
  • Repeat the above between 06:00 and 12:00 and again between 18:00 and midnight. Do this for 7 consecutive days and input below.

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
/
1st Evening Measurement
/
2nd Evening Measurement
/

Average Blood Pressure (Morning and Evening)

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

Morning Measurement

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Evening Measurement
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Overall Average Blood Pressure

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

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