Blood pressure review

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Smoking status

Smoker

Never smoked

Ex-smoker

How many per day do you smoke?

When did you give up smoking?

Your Blood Pressure

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

Day 1

Date:

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

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 2

Date:

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

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 3

Date:

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

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 4

Date:

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

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 5

Date:

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

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 6

Date:

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

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 7

Date:

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

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Confirmation

I confirm that the information provided is accurate to the best of my knowledge

Terms and Conditions: Required

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.

If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency, I will call 999.

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Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure

Temporary Suspension