Ambulatory Blood Pressure form

Blood Pressure

Blood Pressure Questionnaire

First Name

Surname

Date Of Birth

NHS Number

Address

Address Line 1

Address Line 2

City

Postcode

Blood Pressure Questions

1. Do you currently have chest pain or pressure?

Yes

Not sure

2. Do you currently have a severe headache, blurred vision, confusion or seizures?

Yes

Not sure

More than one of these

4. When was your blood pressure last checked?

Never

Within 6 months

6–12 months

More than 12 months ago

5. Have you ever been diagnosed with high blood pressure?

Yes

Not sure

Prefer not to say

7. Are you currently taking medicine for blood pressure?

Yes

Not sure

8. Do you know your most recent blood pressure reading?

Yes

9. Are you pregnant or have you given birth within the last 6 weeks?

Yes

10. Do you have any other medical condition, or take any medicine, that may affect your blood pressure?

Yes

11. Please list relevant medical conditions and all medicines, including over-the-counter medicines, herbal remedies and supplements.

13. Do you drink alcohol?

Yes

14. In the last 30 minutes, have you smoked or vaped, exercised, or had caffeine?

Smoked or vaped

Exercised

Had caffeine

None of these

15. Do you have any allergies?

Yes

16. Please list any allergies and describe the reaction.

17. Please tell us the best times to contact you.

Consent

15. Are you able to come into the Pharmacy for an appointment?

I confirm the information provided is accurate.

I do consent to assessment and GP notification where appropriate.

I understand this questionnaire must be reviewed before my appointment request can be accepted.

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Blood Pressure Questionnaire

Blood Pressure Questions

Consent

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