Ley Hill Surgery Home Blood Pressure Form

Name ……………………………………………… Date of Birth ………………………… Date…………………………

Step 1: Taking your readings

Please measure your blood pressure four times a day, twice in the morning and twice in the evening. Make sure you’ve been sitting for 5 minutes before taking your first reading, then wait 1 minute and take another. Record all readings in the grid below:

Date / 1st Reading / 2nd Reading
Systolic / Diastolic / Systolic / Diastolic
Day 1 / am
pm
Day 2 / am
pm
Day 3 / am
pm
Day 4 / am
pm
Day 5 / am
pm
Day 6 / am
pm
Day 7 / am
pm
Totals
EXCLUDING DAY 1 / A / B / C / D

Step 2: Working out your average(don’t worry if you don’t want to do this part)

Average systolic :(Box A ______+ Box C ______) ÷ 24 = ______

Average diastolic :(Box B______+ Box D ______) ÷ 24 = ______

Step 3: work out the next steps?

Write your BP in this box:

What to do next depends on whether you recorded your BP for diagnosis or monitoring of high blood pressure.

If you are not on medication for high blood pressure and you do not have a prior diagnosis, then you have recorded your BP for diagnosis. If you have been diagnosed with high blood pressure in the past and you are on treatment then you have recorded your BP for monitoring.

For diagnosis:

If your BP is over 135/85 (the top number, the bottom number or both) then it is higher than we would like it and you may benefit from treatment to reduce your BP.Not everyone with a raise BP requires medication. To help you decide whether you would benefit from treatment we need to see whether you have any signs that your BP is causing problems. What happens next:

  1. Return the form to Ley Hill
  2. We will check it and get in touch to arrange an appointment for a blood test (unless you’ve had the right ones recently) and an ECG (heart trace)
  3. You will then need an appointment with a doctor do an examination and discuss your results and treatment options.

If your BP is over 180/110 (the top number, the bottom number or both) then please book in to see a doctor soon to discuss this and bring this sheet with you.

For monitoring:

If your BP is under 135/85 (both numbers) then your treatment is working well and you don’t need to see a doctor unless you want to discuss further. Just drop this sheet back to reception so we can record it. We may contact you if you need any further blood or urine tests which may be required depending on the medication you are on.

If you BP is over 135/85 then you may benefit from adjusting your medication. Please book in to see a doctor at your convenience and bring this sheet with you.

If your BP is over 180/110 (the top number, the bottom number or both) then please book in to see a doctor soon to discuss this and bring this sheet with you

If at any time you have questions about the information contained in this document then please get in touch with the surgery and we will be happy to help.

Please remember to hand this form back to reception so we can make sure the information is recorded

Based on NICE CG127

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