Hypertension review questionnaire

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Home Address (including postcode): Required

Height (in Meters): Required

eg. 1.75

Weight (in Kilograms): Required

eg. 60.6

BMI:

Medication Review

Are you having any problems with your medication? Required

Yes

No

Smoking

Smoking status: Required

Smoker

Never smoked

Ex-smoker

Smoker

How many cigarettes do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking? Required

Yes

No

Ex Smoker

Rollups – How many grams of tobacco did you smoke per week? Required

Pipe – How many grams of tobacco did you smoke per week? Required

When did you give up smoking? Required

Home Blood Pressure Diary

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

Yes

No

Day 1

Date: Required

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Day 1 continued

Evening Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Comments:

Day 2

Date: Required

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Day 2 continued

Evening Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Comments:

Day 3

Date: Required

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Day 3 continued

Evening Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Comments:

Day 4

Date: Required

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Day 4 continued

Evening Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Comments:

Day 5

Date: Required

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Day 5 continued

Evening Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Comments:

Day 6

Date: Required

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Day 6 continued

Evening Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Comments:

Day 7

Date: Required

Please use this date format: DD/MM/YYYY.

Morning Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Day 7 continued

Evening Measurements

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate Required

Comments:

Average Blood Pressure

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

Morning Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Evening Measurements

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Confirmation Required

I confirm that the information provided is accurate to the best of my knowledge

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Hypertension review questionnaire

Medication Review

Smoking

Smoker

Ex Smoker

Home Blood Pressure Diary

Patient Instructions

Day 1

Day 1 continued

Day 2

Day 2 continued

Day 3

Day 3 continued

Day 4

Day 4 continued

Day 5

Day 5 continued

Day 6

Day 6 continued

Day 7

Day 7 continued

Average Blood Pressure