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Waddesdon Surgery

Goss Avenue, Waddesdon, Aylesbury, Bucks, HP18 0LY

Telephone: 01296 658 585

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Blood Pressure – Weekly Readings

Blood Pressure - Weekly Readings

Step 1 of 3 - About You

Name
This field is for validation purposes and should be left unchanged.
If you have been advised by the surgery to submit your blood pressure readings on a regular basis please use this form.

Instructions:
- Don't smoke, drink caffinated drinks or exercise 30 minutes before measuring your blood pressure (BP)
- Ensure 5 minutes of quiet rest before taking your BP.
- Sit with your back straight and supported, your feet flat on the floor and your legs uncrossed. Your arm should be supported on a flat surface with your upper arm at heart level. Don't take the measurement over clothes.
- On each occasion take your blood pressure TWICE and submit the SECOND reading.
- Record your blood pressure TWICE DAILY, ideally in the morning and the evening.
- Record your blood pressure for A TOTAL OF SEVEN DAYS.
Name*
NHS Number (if known)
Date of Birth*
Address*
Telephone
Mobile Tel
Smoking Status
- Smoker
- Ex Smoker
- Never Smoked
How many do you smoke?
When did you give up smoking?

"*" indicates required fields

Phone

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Name*

Title First Last

Date of Birth*

What would you like to update?*

Name

Address

Telephone Number

Email Address

New Name*

Prefix First Last

New Address*

Street Address Address Line 2 Town County Postcode Country

Other family members also moving to this address:

Please provide us with their name and date of birth

New Home Telephone Number

New Mobile Telephone Number

New Work Telephone Number

New Email*

Please upload supporting documentation of name change

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