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.

Measuring your blood pressure to diagnose or monitor your hypertension

Take 2 readings 1 minute apart twice daily, morning and evening for 7 days and submit them on this form.

We consider the blood pressure well controlled if the average is < 135/85 (although you may have a different target particularly if you have diabetes or are over 80 years of age)

Blood Pressure Review (2 readings)

Section

About You

Smoking status

Your Blood Pressure

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

For each blood pressure recording provided, at least two consecutive measurements should be taken, at least one minute apart.

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

This is automatically calculated for internal use only.

Please note: These averages do not include Day 1 readings.

Morning Measurement

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Evening Measurement
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Overall Averages
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*