BP Review If you have been advised by the surgery to submit your blood pressure readings on a regular basis, please use this form. About YouFirst Names Last Name Date of Birth DD slash MM slash YYYY Smoking StatusDo you smoke? Current Smoker Never Smoked Ex Smoker Tell us about your smoking For example, how many cigarettes, e-cigarettes, cigars etc do you smoke each day and week.Tell us about your smoking history When did you give up? How many cigarettes, e-cigarettes, cigars etc did you smoke each day and week.Blood Pressure (BP) Readings (1 to 5)Add as many past readings as you are able. This will give your GP a better understanding of your blood pressure over time.Date of Reading Day Month Year Example: 18/06/2021Time Hours : Minutes Example: 13:45Systolic BP (higher)Please enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower)Please enter a number from 20 to 200.Please enter a number from 20 to 200.Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Add more readings Yes Optional Blood Pressure (BP) Readings (6 to 10)Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Add more readings Yes Optional Blood Pressure (BP) Readings (11 to 15)Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Add more readings Yes Optional Blood Pressure (BP) Readings (16 to 20)Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Date of Reading Day Optional Month Optional Year Optional Example: 18/06/2021Time Hours Optional : Minutes Optional Example: 13:45Systolic BP (higher) OptionalPlease enter a number from 50 to 250.Please enter a number from 50 to 250.Diastolic BP (lower) OptionalPlease enter a number from 20 to 200.Please enter a number from 20 to 200Privacy Policy I consent to the practice collecting and storing my data from this form. 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. The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible. We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. If you are not completely happy to provide information via the internet please contact the practice directly.