Blood Pressure Review

Blood Pressure Reviews

Please complete this section if you are completing the form on behalf of someone else.

About you (The patient)

Name  Required
Date of Birth  Required
Address  Required
What is your sex assigned at birth?  Required

About Your Blood Pressure

Please tell us where you check your blood pressure?  Required
What type of blood pressure monitor are you using?  Required
Do you currently take blood pressure lowering medication?  Required
Do you take your medication(s) exactly as prescribed?  Required
Do you have any side effects with your medication(s)?  Required
Does your medication include Asprin 75mg tablet once a day?  Required
Do you often feel dizzy or unsteady?  Required

Please add your blood pressure readings.

We need at least 3 blood pressure readings to continue and no more than 24 readings in total. This will give your GP a better understanding of your blood pressure over time.
Date of reading  Required
Time  Required
:
Date of reading  Required
Time  Required
:
Date of reading  Required
Time  Required
:
Date of reading  Optional
Time  Optional
:
Date of reading  Optional
Time  Optional
:
Date of reading  Optional
Time  Optional
:
Have any of your parents or siblings been diagnosed with heart disease, angina, peripheral vascular disease, stroke or mini stroke before they were 60 years old?  Required
Please state if in kilograms or stones
Please state if in centimeters or feet.
Do you consume alcohol?  Required
1 pint of beer is approximately two units and one small glass of wine is 1 unit.
Do you smoke?  Required
Do you have any allergies?  RequiredFor example, medications, creams or food.
Are you, or is there a chance you might be, pregnant?  Required
Are you breastfeeding?  Required
Please be aware that this will not be reviewed by a GP or clinician immediately. Therefore, if your matter is urgent, please contact the surgery directly.
Privacy Protection  Required

Additional Information

Carers

Chaperoning

GDPR, Data Processing and Subject Access Request (SAR)

Infection Control

Long Term Conditions

Summary Care Records

Zero Tolerance Policy

Non-NHS Services

Patient Participation Group

Responsibilities

Talking Saves Lives

Winter Health

Community and Locality Services

Complaints Policy