Blood Pressure Review Form If you have been invited by the practice to submit a blood pressure review, please complete this form. Blood Pressure Reading Submission First Name * Last Name * Email * Date of birth * Please use format day/month/year e.g. 06/09/1978 Phone Number * Systolic blood pressure reading * This is the higher number of the two numbers given (eg 120 of 120/80) Diastolic blood pressure reading * This is the lower number of the two numbers given (eg 80 of 120/80) Pulse Rate Most machines also give you your pulse rate and may be marked with a 'P' prior to the number - if this is available, give it here. Are you on medication to help control your blood pressure? * Yes No Do you smoke? * Never smoked Ex smoker Light smoker 1-9 / day Moderate smoker 10-19 / day Heavy smoker 20-39 / day Very heavy smoker 40+ / day Smoking cessation * Yes - I would like help to stop smoking No thanks - not right now N/A I don't smoke Check and Send
