Blood Pressure Monitoring for 5 days

 
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Personal Details

If you have been advised by the surgery to submit your blood pressure readings for 5 days, please use this form once you have taken the readings to submit the information to the practice. If your blood pressure is more than 180/110 please contact the surgery or call 111 out of surgery hours. 

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Health Questions
What is your smoking status?: *
Are you diabetic?: *

Take a readings in the morning and in the evening of each day

  • Sit quietly for 5 mins
  • Take two readings more than one minute apart whilst seated.
  • Record the lowest of the two readings below
Your Blood Pressure Day 1

Day 1 - Measurement

Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute

Evening

Top Number
Bottom Number
Pulse
Your Blood Pressure Day 2

Day 2 - Measurement

Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute

Evening

Top Number
Bottom Number
Pulse
Your Blood Pressure Day 3

Day 3 - Measurement

Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute

Evening

Top Number
Bottom Number
Pulse
Your Blood Pressure Day 4

Day 4 - Measurement

Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute

Evening

Top Number
Bottom Number
Pulse
Your Blood Pressure Day 5

Day 5 - Measurement

Morning

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute

Evening

Top Number
Bottom Number
Pulse
Averages
Diabetic patients and those 80 years and over

If you are diabetic, 80 years and over or almost 80 we would like to check that your blood pressure does not drop significantly when you stand.

  • In addition to the readings above, please can you also take your blood pressure whilst sitting, and then repeat this again 1 minute after standing-up.
  • Please stay standing if possible and repeat again 3 minutes after you have stood up.

Sitting blood pressure

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading

Blood pressure after standing for 1 minute

Top Number
Bottom Number

Blood pressure after standing for 3 minutes

Top Number
Bottom Number

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St Lawrence Surgery
79 St Lawrence Avenue
Worthing
West Sussex
BN14 7JL

Telephone: 01903 222 900

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