Manor Street Surgery > Forms > Blood Pressure – Weekly Readings

Blood Pressure – Weekly Readings

Step 1 of 3 – About You

If you have been advised by the surgery to submit your blood pressure readings on a regular basis please use this form.

Instructions:
- Don’t smoke, drink caffinated drinks or exercise 30 minutes before measuring your blood pressure (BP)
- Ensure 5 minutes of quiet rest before taking your BP.
- Sit with your back straight and supported, your feet flat on the floor and your legs uncrossed. Your arm should be supported on a flat surface with your upper arm at heart level. Don’t take the measurement over clothes.
- On each occasion take your blood pressure TWICE and submit the SECOND reading.
- Record your blood pressure TWICE DAILY, ideally in the morning and the evening.
- Record your blood pressure for A TOTAL OF SEVEN DAYS.
Name*
NHS Number (if known)
Email*
Date of Birth*
DD slash MM slash YYYY
Address*
Telephone
Mobile Tel
Smoking Status
- Smoker
- Ex Smoker
- Never Smoked
How many do you smoke?
When did you give up smoking?