Submit your Blood Pressure Readings

Please take 2 blood pressure readings at least 2 minutes apart in the morning and note down the better of the two. Please also make a note of your heart rate or pulse which is shown on the device.
Please do the same in the evening.
Do this for 7 consecutive days, and then submit your 14 readings below.
These will then be forwarded to your usual GP for review who will arrange to contact you if required.

Blood Pressure Review

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 06/09/1978

Phone Number *

Smoking Status

What is your smoking status?

Smoker

Never smoked

Ex-smoker

How many do you smoke each day?

When did you give up smoking?

Your Blood Pressure

Please provide blood pressure readings for seven consecutive days. Take a readings in the morning and in the evening of each day.

Day 1

Date *

Readings in the Morning

Heart Rate morning *

Systolic morning *

Diastolic morning *

Readings in the Evening

Heart Rate evening *

Systolic evening *

Diastolic evening *

Day 2

Date *

Readings in the Morning

Heart Rate morning *

Systolic morning *

Diastolic morning *

Readings in the Evening

Heart Rate evening *

Systolic evening *

Diastolic evening *

Day 3

Date *

Readings in the Morning

Heart Rate morning *

Systolic morning *

Diastolic morning *

Readings in the Evening

Heart Rate evening *

Systolic evening *

Diastolic evening *

Day 4

Date *

Readings in the Morning

Heart Rate morning *

Systolic morning *

Diastolic morning *

Readings in the Evening

Heart Rate evening *

Systolic evening *

Diastolic evening *

Day 5

Date *

Readings in the Morning

Heart Rate morning *

Systolic morning *

Diastolic morning *

Readings in the Evening

Heart Rate evening *

Systolic evening *

Diastolic evening *

Day 6

Date *

Readings in the Morning

Heart Rate morning *

Systolic morning *

Diastolic morning *

Readings in the Evening

Heart Rate evening *

Systolic evening *

Diastolic evening *

Day 7

Date *

Readings in the Morning

Heart Rate morning *

Systolic morning *

Diastolic morning *

Readings in the Evening

Heart Rate evening *

Systolic evening *

Diastolic evening *

Average Readings

Heart rate morning average

Systolic morning average

Diastolic morning average

Heart rate evening average

Systolic evening average

Diastolic evening average

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Submit your Blood Pressure Readings

Blood Pressure Review

Smoking Status

Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Readings

Privacy Policy

The Simpson Centre

Penn Surgery