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.

Alternatively you can use our Downloadable Blood Pressure Review Form.

Once complete please email your form to GLCCG.therendcombsurgery@nhs.net or drop it in to reception.

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

  • Measure your blood pressure in a relaxed setting, seated with your arm outstretched and supported on a pillow.
  • Record your blood pressure in the morning and evening for 1 week.
  • On each occasion, please measure your blood pressure twice with at least a minute in between.

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 (excluding day 1)

This is automatically calculated for internal use only.

Morning Measurements

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Evening Measurements
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Average Blood Pressure (including day 1)

This is automatically calculated for internal use only.

Morning Measurements

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Evening Measurements
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*