Home Blood Pressure Readings

Use this form to record your blood pressure readings taken at home.

Last Updated: 21/11/2019

Patient Information

Please provide a mobile number if you have one. We will confirm receipt of your home Blood Pressure Readings by SMS message to your mobile if we have a number.

First Name *

Last Name *

Date of Birth *

First line of your home address *

Mobile number

Blood Pressure Readings

Self monitoring of blood pressure is as accurate as readings taken by your doctor. It can be done in the quiet and convenience of your own home. Please get comfortable and try to relax for 5 minutes before checking it initially. Ideally avoid measuring your blood pressure if you have drunk any caffeine containing drinks (such as tea or coffee) or alcohol in the past couple of hours. Please record your blood pressure, sitting down quietly.

Day 1 Readings

If you missed a reading, just put a dash ( - ) in the reading box

Date *

1st Morning Reading *

2nd Morning Reading *

1st Evening Reading *

2nd Evening Reading *

Day 2 Readings

If you missed a reading, just put a dash ( - ) in the reading box

Date *

1ST Morning Reading *

2nd Morning Reading *

1st Evening Reading *

2nd Evening Reading *

Day 3 Readings

If you missed a reading, just put a dash ( - ) in the reading box

Date *

1st Morning Reading *

2nd Morning Reading *

1st Evening Reading *

2nd Evening Reading *

Day 4 Readings

If you missed a reading, just put a dash ( - ) in the reading box

Date *

1st Morning Reading *

2nd Morning Reading *

1st Evening Reading *

2nd Evening Reading *

Day 5 Readings

If you missed a reading, just put a dash ( - ) in the reading box

Date *

1st Morning Reading *

2nd Morning Reading *

1st Evening Reading *

2nd Evening Reading *

Day 6 Readings

If you missed a reading, just put a dash ( - ) in the reading box

Date *

1st Morning Reading *

2nd Morning Reading *

1st Evening Reading *

2nd Evening Reading *

Day 7 Readings

If you missed a reading, just put a dash ( - ) in the reading box

Date *

1st Morning Reading *

2nd Morning Reading *

1st Evening Reading *

2nd Evening Reading *

Overall Average Blood Pressure

If you know how to calculate your average blood pressure from your readings, please put the average below. Don't worry if you cannot calculate the average - we'll do it in the practice for you.

Overall Average Blood Pressure from readings above

Information

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form. *

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Home Blood Pressure Readings

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