Blood Pressure Readings

Please use this form to provide a blood pressure reading (using a home blood pressure monitor). You can purchase a blood pressure monitor online or in local pharmacies. A list of suggested blood pressure monitors can be found at the following address: https://blood-pressure-monitoring.org/monitors-bhs-approved. Before using your monitor, please take time to sit down for a few minutes and relax. We will review all blood pressure readings but will only get in touch with you if any action is needed.

Last Updated: 12/11/2020

Your Contact Details

Title

Name *

Date of Birth *

Address *

Postcode *

Home Number

Mobile Number

If you have an email address, please provide it below

Blood Pressure Readings

Blood Pressure Readings

Date of reading *

Systolic Blood Pressure (SYS) *

Diastolic Blood Pressure (DIA) *

Pulse

Was this reading requested by a GP or nurse?

If applicable, please provide the name of the GP/Nurse

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked?

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes No

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you failed to do what was normally expected of you because of drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Signature

Signature *

Date *

Blood Pressure Readings

Further Information