Blood Pressure Review (2 readings)

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

Please ensure you have read the instructions on your blood pressure monitoring machine:

  • Step 1: Place the blood pressure monitoring cuff on your arm and sit comfortably in an upright seated position.
  • Step 2: Start the machine and record the time and the reading of the systolic (high number) and the diastolic (lower number) in the boxes.
  • Step 3: Rest for 1 minute then repeat, documenting the reading in BP Reading 2. If your machine displays your heart rate, please record this number (normally in BPM, also known as Beats Per Minute.)
  • Step 4: Repeat steps 1-3 later in the day using boxes BP Reading 3 and BP Reading 4.
  • Step 5: Repeat the above for 7 days or a minimum of 4 consecutive days before handing back to your GP or practice.
Blood Pressure Review (2 readings)

Blood Pressure Review (2 readings)

Section

About You

Smoking status

Your Blood Pressure

Please provide a minimum of one blood pressure reading up to a maximum of seven days’ readings.

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

For information on blood pressure and blood pressure measurements, please visit our Wellbeing Centre.

Day 1

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
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2nd Morning Measurement
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1st Evening Measurement
/
2nd Evening Measurement
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Day 2

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

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Evening Measurement
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Home Blood Pressure Measurement (HBPM) - Your Overall Average
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*