Blood Pressure Readings Taken At Home

Please use this form if you have been requested to track and supply a record of your blood pressure readings/pulse. You can supply up to 10 days worth of readings per form.

Last Updated: 19/05/2022

Your Details

Name *

Date of Birth *

Full address and postcode *

Phone Number

Email Address *

Questions

CLINICIAN REQUESTING READINGS IF KNOWN

Smoking Status

Current Smoker

Ex-Smoker

Never Smoked

Height (Metres)

Weight (KG)

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.

BP Readings

Please record all readings in the format "systolic / diastolic" or "higher / lower"

1st Reading Date

Morning reading

Evening reading

pulse

2nd reading date

morning reading

evening reading

pulse

3rd reading date

morning reading

evening reading

pulse

4th reading date

morning reading

evening reading

pulse

5th reading date

morning reading

evening reading

pulse

6th reading date

morning reading

evening reading

pulse

7th reading date

morning reading

evening reading

pulse

8th reading date

morning reading

evening reading

pulse

9th reading date

morning reading

evening reading

pulse

10th reading date

morning reading

evening reading

pulse

SMS Messaging Service

SMS Consent

SMS TEXT MESSAGING IS A SERVICE OFFERED ACROSS WALES WHERE ALL GP PRACTICES HAVE THE ABILITY TO SEND TEXT REMINDERS FOR SMS TEXT MESSAGING AND INFORMATION ABOUT SERVICES TO PATIENTS. IF OFFERED BY MY PRACTICE, I AM HAPPY TO BE CONTACTED VIA SMS TEXT MESSAGING

I DECLINE THE SMS TEXT MESSAGING SERVICE

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Blood Pressure Readings Taken At Home

Further Information