Hypertension Annual Review Patient Questionnaire

SMS Messaging Consent

Do you consent to us sending you information about your medication or condition by SMS messaging to your mobile phone if appropriate? *

Medication Review

Are you having any problems with your medication? *

Smoking

Smoking status *
Do you wish to be sent details of how to access support to help you quit? *

Weight

Home Blood Pressure Diary

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

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.

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

Day 1

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

Evening Measurements
/
/

Day 2

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

Evening Measurements
/
/

Day 3

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

Evening Measurements
/
/

Day 4

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

Evening Measurements
/
/

Day 5

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

Evening Measurements
/
/

Day 6

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

Evening Measurements
/
/

Day 7

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

Evening Measurements
/
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurements

/
Evening Measurements
/
*