Submit a Blood Pressure Reading Name First Last Date of Birth Day Month Year Phone NumberAddress Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Blood Pressure Please provide a minimum of one blood pressure reading, up to a maximum of seven. Day 1Date Day Optional Month Optional Year Optional Morning MeasurementSystolic Top NumberDiastolic Bottom NumberHeart Rate Optional Evening MeasurementSystolic Top NumberDiastolic Bottom NumberHeart Rate Optional Day 2Date Day Optional Month Optional Year Optional Morning MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Evening MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Day 3Date Day Optional Month Optional Year Optional Morning MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Evening MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Day 4Date Day Optional Month Optional Year Optional Morning MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Evening MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Day 5Date Day Optional Month Optional Year Optional Morning MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Evening MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Day 6Date Day Optional Month Optional Year Optional Morning MeasurementDiastolic Optional Bottom NumberSystolic Optional Top NumberHeart Rate Optional Evening MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Day 7Date Day Optional Month Optional Year Optional Morning MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Evening MeasurementSystolic Optional Top NumberDiastolic Optional Bottom NumberHeart Rate Optional Have you previously been diagnosed with Hypertension (High Blood Pressure)? Yes Optional No Optional Why have you submitted these blood pressure readings? My blood pressure was raised in clinic and the doctor/nurse requested I submit. Optional My medication review is due and I was requested to submit them. Optional I submitted a blood pressure reading and it was raised, so I was requested to submit more readings. Optional Other – please write in the comments box below. Optional Comments Optional I confirm that the information provided is accurate to the best of my knowledge