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.

Taking your Blood Pressure at Home

In order for you to submit readings using your own device, we ask that the device meets the following criteria:

  • Is a validated device, see BIHS List
  • Is less than 5 years old
  • An upper arm device is preferred
  • Have an appropriately sized cuff (basked on mid arm circumference)

Patient Information

Blood Pressure Review (2 readings)

Patient Details

About You

Smoking status

Your Blood Pressure

Please provide a minimum of four blood pressure readings, 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
/
2nd Morning Measurement
/
1st Evening Measurement
/
2nd Evening Measurement
/

Day 2

Please use this date format: DD/MM/YYYY.
1st Morning Measurement
/
2nd Morning Measurement
/
1st Evening Measurement
/
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
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

/
Evening Measurement
/
*

For office use only