BP Review 4 days

 

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Personal Details

If you have been advised by the surgery to submit your blood pressure readings for 5 days, please use this form once you have taken the readings to submit the information to the practice.

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May be used to identify you
Health Questions

Take a readings in the morning and in the evening of each day

  • Sit quietly for 5 mins
  • Take two readings more than one minute apart whilst seated.
  • Record both readings in the morning and both readings in the evening
Your Blood Pressure Day 1

Day 1 - Measurement

Morning Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute
Top Number
Bottom Number
 

Evening Evening

Top Number
Bottom Number
Pulse
Top Number
Bottom Number
 
Your Blood Pressure Day 2

Day 2 - Measurement

Morning Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute
Top Number
Bottom Number
 

Evening Evening

Top Number
Bottom Number
Pulse
Top Number
Bottom Number
 
Day 2 Systolic Average
Day 2 Systolic Average
Day 2 Heart Rate Average
Your Blood Pressure Day 3

Day 3 - Measurement

Morning Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute
 

Evening Evening

Top Number
Bottom Number
Pulse
 
Day 3 Systolic Average
Day 3 Diastolic Average
Day 3 Heart Rate Average
Your Blood Pressure Day 4

Day 4 - Measurement

Morning Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute
 

Evening Evening

Top Number
Bottom Number
Pulse
 
Day 4 Systolic Average
Averages from Day 2
Systolic Average
Diastolic Average
Heart Rate Average
Diabetic patients and those 80 years and over

If you are diabetic, 80 years and over or almost 80 we would like to check that your blood pressure does not drop significantly when you stand.

  • In addition to the readings above, please can you also take your blood pressure whilst sitting, and then repeat this again 1 minute after standing-up.
  • Please stay standing if possible and repeat again 3 minutes after you have stood up.

Sitting blood pressure

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading

Blood pressure after standing for 1 minute

Top Number
Bottom Number

Blood pressure after standing for 3 minutes

Top Number
Bottom Number

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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