Admin: Home Blood Pressure Form (7 days)

This page will allow you to submit your home blood pressure readings. They will be recorded in your medical records. If needed, our clinical team will contact you to discuss the results. Taking your blood pressure over a one week period once a year (or as frequently as your GP requests) and recording as shown below will help us monitor your blood pressure.

We would recommend a BP machine with an arm cuff rather then a wrist one, these can be purchased from a chemist or online and are affordable. Please watch this video for instructions on how to complete your blood pressure measurement. The picture below will help you understands the readings produced from the machine.

Blood pressure machine labelled

How to take and record your Blood Pressure Readings:

It is important to take your blood pressure when you are seated and not talking.
Take 2 readings at least a minute apart mornings and evening and record the lowest of the two readings each time
Record these readings for 7 days. Morning and evening.
If your machine records the pulse rate also record this.
Fill in the name of the patient, date of birth and telephone contact (only use one form per patient)
The message box is optional, please use if you think we should know about anything significant such as if you have had to stop any of your medicines.

Once you have all your readings. Calculate your average systolic (upper value) and diastolic (lower value) for the 7 days. You MUST use this online calculator to obtain an accurate average.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 10 working days to complete. Please DO NOT call before 10 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Admin: Home Blood Pressure Form (7 days)

Full Name:

Date of Birth (DD/MM/YYYY):

Date of first Blood Pressure Reading:

Day 1 Blood Pressure (Morning)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 1 Blood pressure (Evening)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse rate

Day 2 Blood Pressure (Morning)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 2 Blood Pressure (Evening)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 3 Blood Pressure (Morning)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 3 Blood Pressure (Evening)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 4 Blood Pressure (Morning)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 4 Blood Pressure (Evening)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 5 Blood Pressure (Morning)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 5 Blood Pressure (Evening)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 6 Blood Pressure (Morning)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 6 Blood Pressure (Evening)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 7 Blood Pressure (Morning)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Day 7 Blood Pressure (Evening)Systolic (Upper value)/Diastolic (Lower value) e.g. 120/80

Pulse ratePlease record the pulse rate if available

Average systolic blood pressure (Upper value)If required use the calculator linked above

Average diastolic blood pressure (Lower value)If required please use the calculator linked above

Any further information regarding your blood pressure submission?

What is your current smoking status?

How many units of alcohol do you consume per week?

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