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.

Taking your Blood Pressure at Home

In order for you to submit readings using your own device, we ask that the device meets the following criteria:

Is a validated device, see BIHS List
Is less than 5 years old
An upper arm device is preferred
Have an appropriately sized cuff (basked on mid arm circumference)

Patient Information

Please be aware that any replies from the surgery may appear in your junk or spam inbox.

Blood Pressure Review (7 to 14 days)

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Section

Confirmation *

I confirm I have added the most up to date phone number

About You

Please provide the name of the person who requested your blood pressure readings (if known):

Smoking status

Smoker

Never smoked

Ex-smoker

How many per day do you smoke?

When did you give up smoking?

Height in Metres:

Weight in Kilograms:

Your Blood Pressure

How many days of readings would you like to submit? *

7 days

14 days

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

Day 1

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 2

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 3

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 4

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 5

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 6

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 7

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 8

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 9

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 10

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 11

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 12

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 13

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Day 14

Date:

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

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only. Averages do not include day 1.

Systolic (Top Number)

Diastolic (Bottom Number)

Heart Rate

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Taking your Blood Pressure at Home

Patient Information

Section

About You

Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Day 10

Day 11

Day 12

Day 13

Day 14

Average Blood Pressure

New Patients