Hypertension review

Home Address (including postcode): *

Height (in Meters): *

eg. 1.75

Weight (in Kilograms): *

eg. 60.6

BMI:

Medication Review

Are you having any problems with your medication? *

Yes

No

Please briefly explain what problems you are having: *

Smoking

Smoking status: *

Smoker

Never smoked

Ex-smoker

Smoker

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week? *

Pipe – How many grams of tobacco do you smoke per week? *

Would you like to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

When did you give up smoking? *

Home Blood Pressure Diary

Do you have access to a home blood pressure monitor? *

Yes

No

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Patient Instructions

In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes.
Then sit in a chair comfortably upright with your arm supported on a table beside you, with both feet on the ground.
Put the cuff on your upper arm (5cm above your elbow) resting on the table, the cuff should be roughly at the level of your heart.
Press the on/start button on the BP monitor and take two readings at least 1 minute apart.
Record the readings below with your pulse rate and any comments.
Repeat that evening & for a total of 7 days using alternate arms. Then return this diary (& BP monitor if borrowed) to the surgery.

Day 1

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 2

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 3

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 4

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 5

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 6

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 7

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Average Blood Pressure

This is automatically calculated for internal use only. Average does not include day 1.

Morning Measurements

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurements

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

*

I confirm that the information provided is accurate to the best of my knowledge

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Medication Review

Smoking

Smoker

Ex Smoker

Home Blood Pressure Diary

Patient Instructions

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure