BP: Submit your blood pressure reading
For patients who suffer from high blood pressure we encourage them to check their BLOOD PRESSURE at HOME as this often gives the best most accurate readings. Sometimes if see the Doctor it may go up - this is called 'white coat syndrome'

**We need only 1 BP reading per YEAR unless you have been told by the surgery for more
Sign in to Google to save your progress. Learn more
Your Details
Please include your latest personal details so that we can contact you if necessary
Your Full Name *
Your Date of Birth *
Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980
Your MOBILE number
If we need to contact you to clarify your answers especially if it HIGH
Your EMAIL address
If we need to contact you to clarify your answers especially if it HIGH
Please submit your blood pressure below. If your BP is above 200/110 please go to AE or ring 111
BP: Your SYSTOLIC blood pressure *
Please submit the TOP blood pressure reading i.e. 120 / 80 - Please type 120 below
Your DIASTOLIC blood pressure *
Please submit the BOTTOM blood pressure reading ie 120 / 80 - Please type 80 below
Other health information
SMOKING: Do you smoke? If so how many? *
Please inform us of your smoking habits including not smoked, ex-smoker or current smoker. If you do smoke and want to stop please ring One for Haringey on 0208 885 9095 or visit: https://www.oneyouharingey.org/
Captionless Image
ALCOHOL: Do You drink? How many units in a week? *
1 pint of beer is approximately two units and one small glass of wine is 1 unit
Captionless Image
Clear form
Never submit passwords through Google Forms.
This form was created inside of hornseywoodgreengp.co.uk. Report Abuse