Hypertension Review

If you have been advised by the surgery to submit details for a hypertension review please use this form.

Please provide a urine sample to reception – sample bottle can be collected from the reception desk.

PLEASE NOTE THAT WE ARE NOT ABLE TO COMPLETE YOUR ASSESSMENT WITHOUT AN UP-TO-DATE BLOOD PRESSURE READING AND URINE SAMPLE.

Please ensure you have booked in for your hypertension/cholesterol blood test. Once these results along with this form is returned, the Practice nurse will review all your details and if needed, they will be in touch.

Last Updated: 17/03/2025

Your Details

Name *

Date of Birth *

Address *

Telephone number *

Hypertension Review

If you would like help with your diet, then please look at the following websites:

https://www.nhs.uk/live-well/eat-well/food-guidelines-and-food-labels/the-eatwell-guide/

https://www.nhsinform.scot/healthy-living/12-week-weight-management-programme/

Do you carry out regular exercise? Yes/no

You should aim to carryout 75 mins of physical exercise per week. If you would like further information, then please have a look at the following website:

https://www.nhs.uk/live-well/exercise/

Height (approximate if not known) *

Weight (approximate if not known) *

Alcohol intake

Bottle of beer/lager/cider 330ml (5%) = 1.7units; Can (5%) 440ml = 2.2units; Pint(5%) = 2.8units;4% beer/cider/larger=2.3 units.

Wine: bottle (13%) 9.8units;250ml (13%) = 3.3 units;175ml (13%) = 2.3mls; Prosecco/wine 250ml11% = 2.8 units; 175mls (11%0 = 1.9 units

Clear spirits 37.5% 25ml (single) = 0.9 units; double 50ml 37.5% (double) = 1.9 units.

Dark spirits single 25ml (40%) = 1 unit; Double 50ml 40% = 2 units.

Help with reducing/stopping alcohol phone 07843339958

What is your average weekly intake of alcohol units? *

Smoking Status

Smoking cessation available from your local pharmacy or NHS quit your way smoking on 0131 537 9914.

Current smoker *

yes

If Yes, how many cigarettes do you smoke daily *

Ex-smoker *

yes

if yes when did you stop? *

never smoked *

yes

Family History

Do you have any family history of cardio vascular disease, myocardial infarct (Heart Attack) or stroke in either 1st degree relative under 60 years of age (parent, sibling-brother, sister), or 2nd degree relative under the age of 50 years of age (aunt, uncle, grandparent, grandchild, niece or nephew)?

Blood Pressure

Please record your blood pressure below. If you do not have one at home or can’t borrow one from a family member or friend, then you are welcome to borrow one of our BP monitors from the surgery.

Blood Pressure *

Would you like to be added to our inhelath BP monitoring system? You would then submit a blood pressure reading once a month. If yes, then the Practice Nurse will be in touch. We would still require a BP reading on this form until you are set up. *

yes

Consent

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. 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.

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Hypertension Review

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