Blood Pressure Review

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Complete this form to let us know your home blood pressure readings.

  • This should be a minimum of 4 days, ideally 7
  • We aim to get back to you in 3 weeks - if you haven't heard from us in that time please get in touch.

MORE INFORMATION AND ADVICE ABOUT BLOOD PRESSURE

All questions marked with a * are mandatory

Personal Details
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Blood Pressure

Take a reading in the Morning and Evening

  • Sit quietly for 5 mins
  • Take two readings more than one minute apart whilst seated
  • Record the lowest of the two readings below
Your 1st set of Readings
 
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
Pulse
 
Your 2nd set of Readings
 
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
Pulse
 
Your 3rd set of Readings
 
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
Pulse
 
Your 4th set of Readings
 
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
Pulse
Do you need to add an additional set of readings: *
Your 5th set of Readings
 
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
Pulse
Do you need to add an additional set of readings: *
Your 6th set of Readings
 
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
Pulse
Do you need to add an additional set of readings: *
Your 7th set of Readings
 
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
Pulse
 

If you need to submit further readings, please complete another form.

  
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Confirmation

Confirm your readings

  • Please return to the previous page to make any corrections

Day 1

Date: 

yyyy-mm-dd

  Morning Evening
Systolic
Diastolic
Heart Rate

Day 2

Date: 

yyyy-mm-dd

  Morning Evening
Systolic
Diastolic
Heart Rate

Day 3

Date: 

yyyy-mm-dd

  Morning Evening
Systolic
Diastolic
Heart Rate

Day 4

Date: 

yyyy-mm-dd

  Morning Evening
Systolic
Diastolic
Heart Rate

Day 5

Date: 

yyyy-mm-dd

  Morning Evening
Systolic
Diastolic
Heart Rate

Day 6

Date: 

yyyy-mm-dd

  Morning Evening
Systolic
Diastolic
Heart Rate

Day 7

Date: 

yyyy-mm-dd

  Morning Evening
Systolic
Diastolic
Heart Rate
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Diabetic patients and those 80 years and over

If you have diabetes, 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.
 

Blood pressure sitting

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
Health Questions
Do you already have a diagnosis of high blood pressure (hypertension)?: *
What is your smoking status?: *
Do you have diabetes?: *
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