Blood Pressure Review If you have been advised by the surgery to submit your blood pressure readings on a regular basis please use this form. Blood Pressure Review About You Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: Email Address: * Smoking status: Smoker Never smoked Ex-smoker How many per day do you smoke? When did you give up smoking? Your Blood Pressure Pressure provide a minimum of one blood pressure reading, up to a maximum of seven. Day 1 Date: Please use this date format: DD/MM/YYYY. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Day 2 Date: Please use this date format: DD/MM/YYYY. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Day 3 Date: Please use this date format: DD/MM/YYYY. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Day 4 Date: Please use this date format: DD/MM/YYYY. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Day 5 Date: Please use this date format: DD/MM/YYYY. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Day 6 Date: Please use this date format: DD/MM/YYYY. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Day 7 Date: Please use this date format: DD/MM/YYYY. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Average Blood Pressure This is automatically calculated for internal use only. Morning Measurement Heart Rate Systolic "Higher" / Diastolic "Lower" Evening Measurement Heart Rate Systolic "Higher" / Diastolic "Lower"