This form can be used to send us your blood pressure readings. It can be used for one off readings or for multiple readings as advised by a doctor or nurse. If you don’t have a BP machine, please visit either Bushey or Elstree surgery and a receptionist will show you where you can use one of our automated machines, you do not need an appointment for this.

Instructions for taking blood pressure:

1. Sit with your arm supported on a table
2. Rest for 1 minute
3. Check blood pressure
4. Repeat process twice more (waiting a full minute between readings) and enter the lowest reading only in the form below.

Blood Pressure Review

About You

Full Name: *

Date of Birth: *

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

Phone Number:

Email Address: *

Smoking status *

Smoker

Never smoked

Ex-smoker

How many per day do you smoke?

If you would like help to stop smoking please make an appointment with one of our nurses or a local pharmacist.

When did you give up smoking?

Your Blood Pressure

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

Day 1

Date:

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

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 2

Date:

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

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 3

Date:

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

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 4

Date:

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

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 5

Date:

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

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 6

Date:

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

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 7

Date:

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

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Afternoon Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

*

I confirm that the information provided is accurate to the best of my knowledge.

*

I have read and understood Schopwick Surgery's Privacy Policy regarding electronic communication and SMS messaging.