Blood Pressure Review Form Blood Pressure Review Your Blood Pressure Please watch the video above on ‘How to take your blood pressure’. • Check the blood pressure 3 times in the morning and 3 times in the evening. • Only record the lowest reading of the 3 from each testing session. • Use the same arm each time. • Record for 7 days so you should have 14 recorded readings in all. • Try to relax and avoid talking whilst using the monitor. • Try to avoid testing within 30 minutes of smoking, eating a large meal, caffeinated coffee, alcohol or vigorous exercise. Make a note on a piece of paper your readings for the next 7 days, one in the morning and one in the evening. At the end of the 7 days, please submit by completing the form below. Name First Last Date of Birth Day Month Year Phone NumberEmail Address Enter Email Confirm Email Day 1Date Day Optional Month Optional Year Optional MorningSystolicTop NumberDiastolicBottom NumberEveningSystolicTop NumberDiastolicBottom NumberDay 2Date Day Optional Month Optional Year Optional MorningSystolicTop NumberDiastolicBottom NumberEveningSystolicTop NumberDiastolicBottom NumberDay 3Date Day Optional Month Optional Year Optional MorningSystolicTop NumberDiastolicBottom NumberEveningSystolicTop NumberDiastolicBottom NumberDay 4Date Day Optional Month Optional Year Optional MorningSystolicTop NumberDiastolicBottom NumberEveningSystolicTop NumberDiastolicBottom NumberDay 5Date Day Optional Month Optional Year Optional MorningSystolicTop NumberDiastolicBottom NumberEveningSystolicTop NumberDiastolicBottom NumberDay 6Date Day Optional Month Optional Year Optional MorningSystolicTop NumberDiastolicBottom NumberEveningSystolicTop NumberDiastolicBottom NumberDay 7Date Day Optional Month Optional Year Optional MorningSystolicTop NumberDiastolicBottom NumberEveningSystolicTop NumberDiastolicBottom NumberAverage of all your readingsAverage Systolic Reading OptionalThis is automatically calculatedAverage Diastolic Reading OptionalThis is automatically calculatedHave you previously been diagnosed with Hypertension (High Blood Pressure)? Yes Optional No Optional Why have you submitted these blood pressure readings? My blood pressure was raised in clinic and the doctor/nurse requested I submit. Optional My medication review is due and I was requested to submit them. Optional I submitted a blood pressure reading and it was raised, so I was requested to submit more readings. Optional Other – please write in the comments box below. Optional Comments OptionalSmoking status Smoker Never smoked Ex-smoker How many per day do you smoke? OptionalWhen did you give up smoking? Optional I confirm that the information provided is accurate to the best of my knowledge