High blood pressure (hypertension) review

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

About you

Height (in Meters): Required

eg. 1.75

Weight (in Kilograms): Required

eg. 60.6

BMI:

Medication

Are you having any problems with your medication? Required

Yes

No

Smoking

Smoking status: Required

Smoker

Never smoked

Ex-smoker

Smoker

How many cigarettes do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking? Required

Yes

No

Ex smoker

Rollups – How many grams of tobacco did you smoke per week? Required

Pipe – How many grams of tobacco did you smoke per week? Required

When did you give up smoking? Required

Blood pressure diary

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Patient instructions

In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes.
Then sit in a chair comfortably upright with your arm supported on a table beside you, with both feet on the ground.
Put the cuff on your upper arm (5cm above your elbow) resting on the table, the cuff should be roughly at the level of your heart.
Press the on/start button on the BP monitor and take two readings at least 1 minute apart.
Record the readings below with your pulse rate and any comments.
Repeat that evening and for a total of 7 days using alternate arms.

Day 1

Date:

Please use this date format: DD/MM/YYYY

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 1 (2nd reading)

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Comments:

Day 2

Date:

Please use this date format: DD/MM/YYYY

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 2 (2nd reading)

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Comments:

Day 3

Date:

Please use this date format: DD/MM/YYYY

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 3 (2nd reading)

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Comments:

Day 4

Date:

Please use this date format: DD/MM/YYYY

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 4 (2nd reading)

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Comments:

Day 5

Date:

Please use this date format: DD/MM/YYYY

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 5 (2nd reading)

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Comments:

Day 6

Date:

Please use this date format: DD/MM/YYYY

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 6 (2nd reading)

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Comments:

Day 7

Date:

Please use this date format: DD/MM/YYYY

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 7 (2nd reading)

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Comments:

Terms and conditions Required

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.

Tell us whether you accept cookies

High blood pressure (hypertension) review

About you

Medication

Smoking

Smoker

Ex smoker

Blood pressure diary

Patient instructions

Day 1

Day 1 (2nd reading)

Day 2

Day 2 (2nd reading)

Day 3

Day 3 (2nd reading)

Day 4

Day 4 (2nd reading)

Day 5

Day 5 (2nd reading)

Day 6

Day 6 (2nd reading)

Day 7

Day 7 (2nd reading)

Average Blood Pressure