Home Blood Pressure Readings

If you have been advised by the surgery to submit a single blood pressure reading, please use the Blood Pressure Reading form by visiting: www.quarterjacksurgery.co.uk/online-forms/blood-pressure-reading

Please use this form if:

• a clinician has requested a set of blood pressure readings
• or
• prior to a medication review for heart failure, hypertension (high blood pressure), chronic kidney disease, high cholesterol

How to take your blood pressure

Sit quietly when you are feeling relaxed and have taken no exercise in the last 30 minutes.

Use a chair that is comfortable and upright. Have your arm supported on a table or the arm of the chair beside you and have both feet on the ground, legs and feet uncrossed.

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 sit still and quietly while your blood pressure is being read as this can affect the reading.

Take two or three readings at least 1 minute apart. Record the lowest of the readings and your pulse rate.

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:

At your last review, were you asked to have an annual blood test?

Yes

No

Have you had this?

Yes

No

Date:

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

Please arrange a blood test appointment.

Do you take medication to control your blood pressure? *

Yes

No

Please state medication and dose taking:

Do you buy aspirin or other medication 'over the counter'? *

Yes

No

Please state medication and dose taking:

Are you having any problems or side effects from your medication? *

Yes

No

Please specify:

Do you have any of the following symptoms: short of breath, dizzy or lightheaded, have palpitations or chest pain? *

Yes

No

If you have chest pain at the moment, please call 999. If you have been having chest pains, lightheadedness or shortness of breath since you last saw your doctor this needs to be discussed urgently, please contact 111 or the surgery as soon as possible and call 999 if you have chest pain or feel very unwell in the meantime.

Do you smoke? *

Yes

No

Do you want to quit?

Yes

No

Which of these applies to you?

Ex-Smoker

Never smoked

Please contact LiveWell Dorset on 0800 8401 628 or visit www.livewelldorset.co.uk

What is your weight: *

How active are you?

Not at all active

Moderately active

Very active

Would you like a flu vaccination? *

Yes

Already had this season

No

Please state date/place:

Are you 65+ or in an eligible group?

Yes

No

Bookings are taken every autumn for flu clinics - don't forget to book your appointment while stocks of vaccine last.

Private vaccination is available from The Wimborne Travel Clinic.

Please note that the details you give will be used to update your medical records.

Please contact the surgery for an appointment.

For managing blood pressure at home, we recommend an approved upper arm Blood Pressure Machine, available to purchase from many chemists.

Please give 7 days readings where possible.

Day 1

Morning Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Afternoon Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Day 2

Morning Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Afternoon Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Day 3

Morning Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Afternoon Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Day 4

Morning Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Afternoon Reading:

Systolic "Higher" *

/

Diastolic "Lower" *

Pulse *

Day 5

Morning Reading:

Systolic "Higher"

/

Diastolic "Lower"

Pulse

Afternoon Reading:

Systolic "Higher"

/

Diastolic "Lower"

Pulse

Day 6

Morning Reading:

Systolic "Higher"

/

Diastolic "Lower"

Pulse

Afternoon Reading:

Systolic "Higher"

/

Diastolic "Lower"

Pulse

Day 7

Morning Reading:

Systolic "Higher"

/

Diastolic "Lower"

Pulse

Afternoon Reading:

Systolic "Higher"

/

Diastolic "Lower"

Pulse

Average Blood Pressure

This is automatically calculated for internal use only.

Overall:

Systolic "Higher"

/

Diastolic "Lower"

Pulse