Blood Pressure Form

Add as many past readings as you are able. This will give the clinician a better idea of your blood pressure overtime. If the reading is dangerously high, you should repeat it immediately and if it remains above 180/110 urgently contact 111, or the surgery. If the reading is dangerously low, you should repeat it immediately and if it remains below 80/50 urgently contact 111, or the surgery.

Your Details

Full Name *

Address (Including Postcode) *

Date of Birth (DD/MM/YYYY) *

Contact Number *

Email Address *

BLOOD PRESSURE READING ONE

Date of Reading *

Time of Reading for example 13:45 *

Systolic BP (Higher) *

Diastolic BP (Lower) *

BLOOD PRESSURE READING TWO

Date of Reading *

Time of Reading for example 13:45 *

Are you experiencing any undesired side effects? *

Yes No

Systolic BP (Higher)

Diastolic BP (Lower) *

Yes No

BLOOD PRESSURE READING THREE

Date of Reading *

Time of Reading for example 13:45 *

Systolic BP (Higher) *

Diastolic BP (Lower) *

If you selected any of the above conditions please provide more details

13. 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.

ADDITIONAL QUESTIONS

IMPORTANT INFORMATION

If the reading is dangerously high, you should repeat it immediately and if it remains above 180/110 urgently contact 111, or the surgery. If the reading is dangerously low, you should repeat it immediately and if it remains below 80/50 urgently contact 111, or the surgery.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Blood Pressure Form

Further Information