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Five Valleys Medical Practice NHS GP Surgery in Stroud

Blood pressure review

Blood Pressure Review (2 readings)

Smoking

Smoking status

Smoker

Never smoked

Ex-smoker

Smoker

What do you mainly smoke?

Cigarettes

Cigars

Rollups

Pipe

E Cigarettes

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week? *

Pipe – How many grams of tobacco do you smoke per week? *

Would you like to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

What did you mainly smoke?

Cigarettes

Cigars

Rollups

Pipe

E Cigarettes

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

When did you quit smoking?

Your Blood Pressure

Please wait until you have recorded all your blood pressure readings before submitting the form below.

For each blood pressure recording provided, at least two consecutive measurements should be taken, at least one minute apart.

Day 1

Date:

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

1st Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

1st Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 2

Date:

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

1st Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

1st Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 3

Date:

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

1st Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

1st Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 4

Date:

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

1st Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

1st Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 5

Date:

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

1st Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

1st Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 6

Date:

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

1st Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

1st Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 7

Date:

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

1st Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

1st Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

2nd Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only.

Please note: These averages do not include Day 1 readings.

Morning Measurement

Morning Average Systolic

/

Morning Average Diastolic

Morning Average Heart Rate

Evening Measurement

Evening Average Systolic

/

Evening Average Diastolic

Evening Average Heart Rate

Home Blood Pressure Measurement (HBPM) – Your Overall Average

Overall Average Systolic

/

Overall Average Diastolic

Overall Average Heart Rate

Confirmation *

I confirm that the information provided is accurate to the best of my knowledge

If you are human, leave this field blank.

1A King Street
Stroud
Gloucestershire
GL5 3BS

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01453 764 222

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