Blood Pressure Review

Form only to be completed if requested by the practice.

If you have been advised by the surgery to submit your blood pressure readings on a regular basis please use this form.

If your overall average blood pressure is more than 135/85 mmHg then you may need to start blood pressure medication or your current medication regime may need to be adjusted. Based on your submitted readings we will contact if this is the case. However, if your readings are above 135/85 mm Hg and you do not hear from us then please do submit a “Get Help for any Health Problem” form to bring this to our attention. For you guidance please note:

  • BP 135/85 mmHg or higher may indicate stage 1 Hypertension
  • BP 150/95 mmHg or higher may indicate stage 2 Hypertension
  • Systolic BP 180mmhg or higher, Diastolic BP 110mmHg or higher may indicate Severe Hypertension
Blood Pressure Review

Blood Pressure Review

Smoking status

Your Blood Pressure

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

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

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Evening Measurement
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Overall Average

This is automatically calculated for internal use only.

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