Blood Pressure Review

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Blackheath Medical Centre
Kings Lane Medical Centre

You will need to have some way of checking your blood pressure. Please take two readings twice daily for 4-7 days.

Please enter your initials (up to 4 characters) *

Please enter your date of birth (d/m/yyyy) *

YYYY

Please enter either your patient (EMIS) number OR your NHS number if you know them. Your NHS number is on your prescription counterfoil.

Which practice do you attend? *

Blackheath Medical Centre, Reeds Lane, Moreton

Kings Lane Medical Centre, Higher Bebington

How much do you weigh please? You can give it to us in Kg, or Stones & pounds (st & lb)

Do you smoke? *

Never smoked

Ex smoker

I smoke 1-9 cigarettes per day

I smoke 1-19 cigarettes per day

I smoke 20-39 cigarettes per day

I smoke 40 or more cigarettes every day

I use an e-cigarette

Other:

Please enter your blood pressure readings. Separate each reading with a comma (",") or semi-colon (";"). *

E.g. 120/80, 125/82; 130/78; 160/78, 123/79, 119/78. Please enter at least 4 readings and up to 28. We run analyses on your figures so please enter the readings in the order they were taken.

How many units are in various drinks?

How many units of alcohol do you drink every week? A unit of alcohol is a small glass of wine (150ml), a pub single measure of spirits, or a half-pint of beer.

Have you any problems with your medications?

Before you finish, please check that you have entered your date of birth correctly. We need this with your initials or your EMIS/NHS number to identify you.

Thank you. When you click "Submit" your responses will be sent to your practice. Your doctors will consider your blood pressure readings. If they are content with your readings they might just send you a brief message. If they think your readings are too high they will telephone you. Thank you for using this review process.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms