Hypertension annual review

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Medication Review

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Smoking

Smoking status *

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Ex-smoker

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When did you give up smoking? *

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Weight

Please enter your current weight if you can measure it at home (in Kg if possible):

Home Blood Pressure Diary

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

Yes

No

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

Date: *

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

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 2

Date: *

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

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 3

Date: *

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

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 4

Date: *

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

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 5

Date: *

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

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 6

Date: *

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

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Day 7

Date: *

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

Morning Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurements

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Comments:

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurements

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurements

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

*

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SMS Messaging Consent

Medication Review

Smoking

Weight

Home Blood Pressure Diary

Patient Instructions

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure