Home Blood Pressure Monitoring

If you have been advised by the surgery to submit home blood pressure readings please use this form.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Home Blood Pressure Monitoring

Please take your blood pressure twice daily, morning and evening, for 5 days.

On each occasion ensure you are sitting comfortably with your arm supported, apply your blood pressure cuff and press the button on your device. Ignore the 1st reading, press the button again and record the 2nd reading you obtain.

Please record readings as e.g. "140 / 80". You do not need to record the "pulse" readings.

Day1: am *

Day 1: pm *

Day 2: am *

Day 2: pm *

Day 3: am *

Day 3: pm *

Day 4: am *

Day 4: pm *

Day 5: am *

Day 5: pm *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 07 April 2026
Page created: 07 April 2026

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Home Blood Pressure Monitoring

Home Blood Pressure Monitoring

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