Hypertension Annual Review Form

Please complete this form to allow our Practice Nurse to complete your annual hypertension review. Please answer each question to the best of your knowledge and submit this to us. Your form will be added to your medical records and reviewed by the Practice Nurse who will only contact you if further management is required.

Your Details

Name

Date of Birth

Address

Postcode

Home telephone number

Mobile telephone number

Should you wish to decline an annual review

I wish to decline Hypertension review. I understand the importance of this but do not wish to partake this year. I further understand that should I change my mind, I can complete this review at any time.

Opt out

Hypertension Review

Have you completed the steps outlined on our website?

Please confirm that you will arrange an appointment for an annual blood test and blood pressure check with the phlebotomist. If you have your own blood pressure monitor, please complete home blood pressure monitoring sheet available on the Chronic Disease home page.

Yes

Height

Weight

Do you smoke?

If yes, how many do you smoke per day?

How many units of alcohol do you drink per week?

How much exercise do you take per week?

Home Blood Pressure Management: BP Monitor and BP Form

Your doctor wishes to confirm your current blood pressure with some home readings. The national Institute for health and Clinical Excellence (NICE) have issued guidance on how this should be performed. Please follow the instructions below and enter your reading into the table.

Readings are required to be taken over a 7 day period, Please;

Take your blood pressure while seated

Take readings twice a day, ideally in the morning and the evening

Two readings at least 1 minute apart are required at each sitting

Please record your reading in the table below in the following format 120/80

Please return completed form and Blood Pressure monitor to: Cowdenbeath Medical Practice 173 Stenhouse Street, Cowdenbeath, KY4 9DH.

Day 1

Date

Morning Reading 1

Evening Reading 1

Morning Reading 2

Evening Reading 2

Day 2

Date

Morning Reading 1

Evening Reading 1

Morning Reading 2

Evening Reading 2

Day 3

Date

Morning Reading 1

Evening Reading 1

Morning Reading 2

Evening Reading 2

Day 4

Date

Morning Reading 1

Evening Reading 1

Morning Reading 2

Evening Reading 2

Day 5

Date

Morning Reading 1

Evening Reading 1

Morning Reading 2

Evening Reading 2

Day 6

Date

Morning Reading 1

Evening Reading 1

Morning Reading 2

Evening Reading 2

Day 7

Date

Morning Reading 1

Evening Reading 1

Morning Reading 2

Evening Reading 2

This form collects your name, date of birth, email and other personal information along with certain medical details. This is to confirm that you are a registered patient with Cowdenbeath Medical Practice to allow the Practice team to contact you to discuss the management of your medical care and also to update the records that we hold. For further information on how we protect and manage your submitted data please read our privacy policy.

I consent to the Practice collecting and storing my data from this form.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Cowdenbeath Medical Practice • 173 Stenhouse Street, Cowdenbeath, Fife, KY4 9DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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