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.

Please monitor and record your blood pressure at home for 7 consecutive days (minimum 5). Remember to bring this diary with you to your next appointment/review.

When to measure:

  • Monitor your blood pressure in the morning and evening at roughly the same time
  • Measure your morning blood pressure before you take your medication
  • Don’t exercise, smoke, eat or drink caffeine in the 30 minute before measurements
  • If you are taking blood pressure medication, monitor your blood pressure a minimum of 1.5 hours after taking the drug

Measuring blood pressure:

  • Do sit quietly for 5 minutes before starting measurements (no TV, talking, reading, phone use)
  • Do sit with feet flat on the floor, legs uncrossed, upper arm bare, back and arm supported with upper arm at the level of the heart
  • Do write down the numbers in the form exactly as they appear on the monitor screen – do not round them up or down
  • Do take a minimum of two readings, leaving at least a minute between each. If the first two readings are very different, take 2 or 3 further readings. Write down the average of the last 2 readings. Note the number taken
Blood Pressure Review

Blood Pressure Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Smoking status

Your Blood Pressure

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

If you are taking blood pressure medication, monitor your blood pressure a minimum of 1.5 hours after taking the drug.

Day 1

Please record the lowest of two readings, one for the morning and one for the evening.
Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 2

Please record the lowest of two readings, one for the morning and one for the evening.
Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 3

Please record the lowest of two readings, one for the morning and one for the evening.
Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 4

Please record the lowest of two readings, one for the morning and one for the evening.
Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 5

Please record the lowest of two readings, one for the morning and one for the evening.
Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 6

Please record the lowest of two readings, one for the morning and one for the evening.
Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 7

Please record the lowest of two readings, one for the morning and one for the evening.
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

/
Evening Measurement
/
*