Blood Pressure Review

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

Blood Pressure Review

Blood Pressure Review

Smoking Status

Do you currently smoke?
Have you smoked in the past?
How many cigarettes did you smoke in a day?
How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Smoking cessation support is available at the practice, through local pharmacies and via the NHS website.

If you would like to consider giving up smoking in future, please contact the surgery who will be able to offer support.

Your Blood Pressure

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

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
/

Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

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Evening Measurement
/
Radio Buttons
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