Benhill and Belmont GP Centre > Services > Forms > Health Review Forms > Hypertension Review Form

Hypertension Review Form

Hypertension Review

First Name *

Last Name *

Email *

Enter Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Your Height and Weight

Weight

Unit of measurement *

Height

Weight

Height

Inches

Weight

lbs

BMI

Underweight

Healthy

Overweight

Obese

Hypertension Review

Upload your weeks’ blood pressure readings *

Maximum file size: 10MB

We accept jpeg, gif, png, tif, pdf, and word files up to 5MB.

Do you smoke *

Yes

How active are you? *

not at all

a little

active

very active

Could you eat more healthy? *

Yes

Phone Number to contact you *

One of our clinicians will contact you on this number in the next couple of weeks.

The practice will be in contact. Any comments you would like to add?

Privacy Policy

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.

Your consent *

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

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IMPORTANT NOTICE

Hypertension Review Form

Your Height and Weight

Weight

BMI

Hypertension Review

Privacy Policy