Blood Pressure Review Please only use this form if you have been advised by the surgery to submit a blood pressure reading. Name First Last Email Enter Email Confirm Email Phone numberDate of birth DD slash MM slash YYYY Smoking status Smoker Ex smoker Never smoked Are you diabetic? Yes No Take a reading at any time of the day Sit quietly for 5 minutes. Take two readings more than one minute apart whilst seated. Record the second of the two readings belowDate of reading DD slash MM slash YYYY Heart Rate:Your heart rate is the number of times your heart beats per minute.Systolic:Your systolic blood pressure is the top number on your reading.Diastolic:Your diastolic blood pressure is the bottom number on your reading.Privacy ConsentThis form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form.