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.

High blood pressure happens when the force on the walls of blood vessels (caused by the blood within them) is more than normal. Find out more about high blood pressure by visiting the following sites:

Please follow this link for information on what Blood Pressure monitor to buy for home use:

https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/tests/blood-pressure-measuring-at-home

If you are human, leave this field blank.

About You

Full Name: *

Phone Number:

Height:

Please give this information in meters and centimeters.

Weight:

Please give this information in KG.

Smoking status

Smoker

Never smoked

Ex-smoker

Electronic Cigarette User

How many per day do/did you smoke?

If you are a current smoker we strongly advise you to stop smoking. The practice runs a Smoking Cessation Clinic offering support and advice. An appointment can be made by contacting the surgery on 01926 859955.

Blood Pressure Reading

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

I confirm that the information is accurate to the best of my knowledge and I understand that this is not an emergency and the practice will only respond if further intervention is required.

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