Home Blood Pressure Monitoring Form - The Lakes Medical Practice
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1HOME BLOOD PRESSURE MONITORING FORM - THE LAKES MEDICAL PRACTICE
Name:
DOB: ______________
Address:
MORNING
EVENING
DAY 1
Reading 1
Reading 2
Reading 1
Reading 2
DAY 2
Reading 1
Reading 2
Reading 1
Reading 2
DAY 3
Reading 1
Reading 2
Reading 1
Reading 2
DAY 4
Reading 1
Reading 2
Reading 1
Reading 2
DAY 5
Reading 1
Reading 2
Reading 1
Reading 2
DAY 6
Reading 1
Reading 2
Reading 1
Reading 2
DAY 7
Reading 1
Reading 2
Reading 1
Reading 2
EXAMPLE:
MORNING
EVENING
DAY 1
Reading 1
Reading 2
Reading 1
Reading 2
01/01/2012
140/87
135/67
145/76
130/56
Take blood pressure when seated around the same time in the morning and evening every day for a
week. Wait at least one minute between the first and second reading. Please return the completed
form to reception. Remember to fill in your details and the dates of your readings.
Document saved in Hypertension Folder/Intranet
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