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

If we need to contact you regarding the submission of your form, we may respond directly through the website and aim to do this within 5 working days of receipt of your form. You will be notified of any responses via email. Please remember to check your email account’s spam/junk folder.

If you do not have your own home blood pressure machine, your GP may suggest borrowing one from the practice. We have a limited number of blood pressure machines for loan and are currently running a waiting list for these. If you require the loan of a blood pressure machine, please contact our reception team on 01635 248251 (option 4) to be added to the waiting list. Please note that you will be contacted when a machine becomes available. You will be asked to provide us with a refundable £10 cash-only deposit for the loan of the machine. This will be payable on collection and will be returned to you in full when you return the blood pressure machine.

Blood Pressure Review

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Responses we send will go to this email address

Smoking status

Smoker

Never smoked

Ex-smoker

How many per day do you smoke?

When did you give up smoking?

Your Blood Pressure

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

Day 1

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 2

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 3

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 4

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 5

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 6

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Day 7

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

Evening Measurement

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

*

I confirm that the information provided is accurate to the best of my knowledge.

*

I confirm that I am currently within the UK at the time of sending my enquiry.