Blood Pressure Medication Review – The Quarter Jack Surgery

Your details

Phone number(Required)

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.

Please be specific(Required)

Please arrange a blood test appointment.

Medication

Please state medication and dose taking(Required)

Please provide details(Required)

If no, please provide details(Required)

If yes, please provide details.(Required)

Please specify(Required)

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 pains or feel very unwell in the meantime.

Please provide details(Required)

Lifestyle

Please contact LiveWell Dorset on 0800 840 1628 or visit https://www.livewelldorset.co.uk/.

What is your weight?(Required)

What is your height?(Required)

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

Please contact the surgery for an appointment.

Your blood pressure readings

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

Please give seven days' readings where possible.

Day 1 morning systolic(Required)

(top number)

Day 1 morning diastolic(Required)

(bottom number)

Day 1 morning heart rate(Required)

(beats per minute)

Day 1 evening systolic(Required)

(top number)

Day 1 evening diastolic(Required)

(bottom number)

Day 1 evening heart rate(Required)

(beats per minute)

Day 2 morning systolic(Required)

(top number)

Day 2 morning diastolic(Required)

(bottom number)

Day 2 morning heart rate(Required)

(beats per minute)

Day 2 evening systolic(Required)

(top number)

Day 2 evening diastolic(Required)

(bottom number)

Day 2 evening heart rate(Required)

(beats per minute)

Day 3 morning systolic(Required)

(top number)

Day 3 morning diastolic(Required)

(bottom number)

Day 3 morning heart rate(Required)

(beats per minute)

Day 3 evening systolic(Required)

(top number)

Day 3 evening diastolic(Required)

(bottom number)

Day 3 evening heart rate(Required)

(beats per minute)

Day 4 morning systolic(Required)

(top number)

Day 4 morning diastolic(Required)

(bottom number)

Day 4 morning heart rate(Required)

(beats per minute)

Day 4 evening systolic(Required)

(top number)

Day 4 evening diastolic(Required)

(bottom number)

Day 4 evening heart rate(Required)

(beats per minute)

Day 5 morning systolic(Required)

(top number)

Day 5 morning diastolic(Required)

(bottom number)

Day 5 morning heart rate(Required)

(beats per minute)

Day 5 evening systolic(Required)

(top number)

Day 5 evening diastolic(Required)

(bottom number)

Day 5 evening heart rate(Required)

(beats per minute)

Day 6 morning systolic(Required)

(top number)

Day 6 morning diastolic(Required)

(bottom number)

Day 6 morning heart rate(Required)

(beats per minute)

Day 6 evening systolic(Required)

(top number)

Day 6 evening diastolic(Required)

(bottom number)

Day 6 evening heart rate(Required)

(beats per minute)

Day 7 morning systolic(Required)

(top number)

Day 7 morning diastolic(Required)

(bottom number)

Day 7 morning heart rate(Required)

(beats per minute)

Day 7 evening systolic(Required)

(top number)

Day 7 evening diastolic(Required)

(bottom number)

Day 7 evening heart rate(Required)

(beats per minute)

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Total systolic

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Total diastolic

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Total heart rate

Average systolic (4 days)

Average diatolic (4 days)

Average heart rate (4 days)

Average systolic (5 days)

Average diatolic (5 days)

Average heart rate (5 days)

Average systolic (6 days)

Average diatolic (6 days)

Average heart rate (6 days)

Average systolic (7 days)

Average diatolic (7 days)

Average heart rate (7 days)

Please note if your heart rate is higher than 180/110 then you may need urgent treatment and to attend your local A and E department.