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01642 618170
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Queens Park Medical Centre
Farrer St
Stockton-on-Tees
TS18 2AW
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Queens Park Medical Centre
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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.