Blood Pressure Reading

If you are on medication for high blood pressure, have been asked to submit several BP readings  or need a cardiac or hypertension review, please use the High Blood Pressure Review form https://www.quarterjacksurgery.co.uk/online-forms/high-blood-pressure-review/

If you have been advised by the surgery to submit a single blood pressure reading, please use this form.

About You

Full Name: *

Date of Birth: *

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

Phone Number:

Email Address: *

By giving us your email address on this online form, we assume consent to reply to this form via email when necessary. If you prefer not to receive email, please contact the surgery by telephone.

Do you have any communication/information needs relating to disability, impairment or sensory loss?

Yes

No

Please be specific:

Smoking status

Smoker

Never smoked

Ex-smoker

Would you like help to give up smoking?

Yes

No

Please contact LiveWell Dorset on 0800 8401 628 or http://www.livewelldorset.co.uk/index.html.

When did you give up smoking?

Date:

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

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Pulse

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Pulse