Hypertension Review Questionnaire

If you are due for a review because you have a diagnosis of hypertension (high blood pressure), please complete this form.

Please answer the following questions. The answers you give will help us to determine the most appropriate way to carry out your review.

Hypertension Review Questionnaire

eg. 1.75
eg. 60.6

Medication Review

Are you having any problems with your medication? *

Smoking

Smoking status: *

Smoker

What do you mainly smoke?
How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

What did you mainly smoke?
How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

Home Blood Pressure Diary

Do you have access to a home blood pressure monitor? *

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Patient Instructions

  • In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes.
  • Then sit in a chair comfortably upright with your arm supported on a table beside you, with both feet on the ground.
  • Put the cuff on your upper arm (5cm above your elbow) resting on the table, the cuff should be roughly at the level of your heart.
  • Press the on/start button on the BP monitor and take two readings at least 1 minute apart.
  • Record the readings below with your pulse rate and any comments.
  • Repeat that evening & for a total of 7 days using alternate arms. Then return this diary (& BP monitor if borrowed) to the surgery.

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurements
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Evening Measurements
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Average Blood Pressure

This is automatically calculated for internal use only. Average does not include day 1.

Morning Measurements

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Evening Measurements
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*
*