Blood Pressure Review Form

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Personal Details

If you have been advised by the surgery to submit a blood pressure reading

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Health Questions

Take a reading at any time of the day

  • Sit quietly for 5 mins
  • Take two readings more than one minute apart whilst seated.
  • Record the second of the two readings below
Your Blood Pressure

Measurement

 
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
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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