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 Diary and Review

Blood Pressure Diary and Review

Patient Details

Please use date format: DD/MM/YYYY

Smoking

Smoking status *
How many cigarettes did you smoke in a day?
How many cigarettes do you smoke in a day?
Would you like help to give up smoking?

Home Blood Pressure Diary

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 & for a total of 4-7 days. If you have postural hypotension, please measure standing blood pressure. Then return this diary (& BP monitor if borrowed) to the surgery.

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

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Average Blood Pressure

This is automatically calculated for internal use only. Average does not include day 1.

Morning Measurements

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Evening Measurements
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