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Blood Pressure – Weekly Readings

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Blood Pressure – Weekly Readings

Blood Pressure – Weekly Readings

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Step 1 of 3 - About You

If you have been advised by the surgery to submit your blood pressure readings on a regular basis please use this form.

Instructions:

Don't smoke, drink caffinated drinks or exercise 30 minutes before measuring your blood pressure (BP)
Ensure 5 minutes of quiet rest before taking your BP.
Sit with your back straight and supported, your feet flat on the floor and your legs uncrossed. Your arm should be supported on a flat surface with your upper arm at heart level. Don't take the measurement over clothes.
On each occasion take your blood pressure TWICE and submit the SECOND reading.
Record your blood pressure TWICE DAILY, ideally in the morning and the evening.
Record your blood pressure for A TOTAL OF SEVEN DAYS.

Personal Information

Name*

First Surname

Date of Birth*

NHS Number (if known)

Smoking Status

Smoker

Ex Smoker

Never Smoked

How many do you smoke?

When did you give up smoking?

Day 1

AM

Systolic (upper reading)*

Diastolic (lower reading)*

PM

Systolic (upper reading)*

Diastolic (lower reading)*

Day 2

AM

Systolic (upper reading)*

Diastolic (lower reading)*

PM

Systolic (upper reading)*

Diastolic (lower reading)*

Day 3

AM

Systolic (upper reading)*

Diastolic (lower reading)*

PM

Systolic (upper reading)*

Diastolic (lower reading)*

Day 4

AM

Systolic (upper reading)*

Diastolic (lower reading)*

PM

Systolic (upper reading)*

Diastolic (lower reading)*

Day 5

AM

Systolic (upper reading)*

Diastolic (lower reading)*

PM

Systolic (upper reading)*

Diastolic (lower reading)*

Day 6

AM

Systolic (upper reading)*

Diastolic (lower reading)*

PM

Systolic (upper reading)*

Diastolic (lower reading)*

Day 7

AM

Systolic (upper reading)*

Diastolic (lower reading)*

PM

Systolic (upper reading)*

Diastolic (lower reading)*

Average Blood Pressure

This is your average blood pressure reading. The calculation has ignored day 1 (as this was when you were just getting used to the monitor) and is an average of the remaining readings.

Average Systolic*

Average Diastolic*

Requesting Doctor

If a specific Doctor requested you send this in, please add their name here - if not, please leave this box blank.

Please click below to submit this form to the Practice

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