Blood pressure form

First name

Surname

Date of Birth

Contact number

Email address

Reason for submitting a BP form

Name of the requesting GP

Blood pressure reading 1

Date

Time

Systolic (upper reading)

Diastolic (lower reading)

Blood pressure reading 2

Date

Time

Systolic (upper reading)

Diastolic (lower reading)

Blood pressure reading 3

Date

Time

Systolic (upper reading)

Diastolic (lower reading)

Additional Questions

Are you on regular blood pressure tablets

In a typical month how many times do you forget to take your tablets

Do you have any concerns regarding your blood pressure

Is there anything you'd like to let us know about the reading you are submitting?

If you have selected other, please expand on your readings submitted

What is your height in centimeters

What is your weight in kilograms

What is your BMI

Do you smoke?

Would you like help in cutting down or stopping smoking?

Do you drink any alcohol Single small shot of spirits* 25ml, ABV 40%= 1 unit ; Alcopop (275ml, ABV 5.5%) = 1.5 units; Small glass of red/white/rosé wine (125ml, ABV 12%)= 1.5 units; Bottle of lager/beer/cider (330ml, ABV 5%) 1.5 units; Can of lager/beer/cider (440ml, ABV 5.5%)= 2.4 units; Pint of lower-strength lager/beer/cider (ABV 3.6%)= 2 units; Standard glass of red/white/rosé wine (175ml, ABV 12%)= 2.1 units; Large glass of red/white/rosé wine (250ml, ABV 12%)= 3 units; Pint of higher-strength lager/beer/cider (ABV 5.2%)= 3 units

Are you concerned about the amount of alcohol you consume?

Here are some useful links:

info@cavdas.com

Alcohol support - NHS (www.nhs.uk)

Alcohol and Drugs (cardiff.gov.uk)

Do you have any family histoy of high blood pressure, heart disease, heart attacks, strokes

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Blood pressure form

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