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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.

Full Name:


Date of Birth:


Phone Number:


Email Address:


Smoking status:
Smoker
Never smoked
Ex-smoker

Your Blood Pressure

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

Day 1

Date:


Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Day 2

Date:


Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Day 3

Date:


Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Day 4

Date:


Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Day 5

Date:


Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Day 6

Date:


Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Day 7

Date:


Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":




Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Evening Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":


Overall Average Measurement

Heart Rate:
Systolic "Higher":
/
Diastolic "Lower":




I confirm that I am currently within the UK at the time of sending my enquiry.