Please take your readings using a home monitor. If you do not have access to a blood pressure machine, please contact the surgery to make a routine appointment with a nurse or health care assistant.

Hypertension Blood Pressure Readings

Patient Details

Full Name: *

Date of Birth: *

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

Phone Number:

Email Address: *

Address (including postcode):

Height (cm):

Weight (kg):

Blood Pressure Readings (Day 1, 2, 3)

Make sure you are sat comfortably. Take your first reading, wait 5 minutes, and take your blood pressure again disregarding the first reading.

Date and time taken:

Systolic (Higher)

Diastolic (Lower)

Pulse

Date and time taken:

Systolic (Higher)

Diastolic (Lower)

Pulse

Date and time taken:

Systolic (Higher)

Diastolic (Lower)

Pulse

Alcohol

This is one unit of alcohol:

And each one of these, is more than one unit:

Weekly consumption, please write how many of each you consume in one week:

Pints of beer or cider:

Measure (25ml) of spirits:

Glass of wine (125ml):

Smoking

What is your daily consumption?

Never smoked

Ex-smoker

Trivial smoker (<1 a day)

Light smoker (1-9 a day)

Moderate smoker (10-19 a day)

Heavy smoker (20-39 a day)

Very heavy smoker (40+ a day)

Use an electronic cigarette or a vape

Would you like advice and support regarding lifestyle (smoking and alcohol) or weight management?

Yes

No

Submit