Blood Pressure Review

If you have been advised by the surgery to submit your blood pressure readings on a regular basis you can either use the automated machine located at the surgery or if you have your own blood Pressure machine please complete this form.

If you would like to self-refer to our Stop Smoking Service please complete our online referral form.

Blood Pressure Review (2 readings)

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
If you smoke, we strongly advise that you stop. If you would like help with this, please complete our self-referral smoking cessation form.

Your Blood Pressure

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

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

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
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2nd Evening Measurement
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Day 2

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
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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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Overall Averages
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