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Middle Chare Medical Group
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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
*
Metric
Imperial
Height
cm
Weight
kg
Height
ft
Inches
in
Weight
lbs
BMI
BMI
Underweight
Healthy
Overweight
Obese
Hypertension Review
Upload your weeks’ blood pressure readings
*
Drop a file here or click to upload
Choose File
Maximum file size: 10MB
We accept jpeg, gif, png, tif, pdf, and word files up to 5MB.
Do you smoke
*
Yes
No
How active are you?
*
not at all
a little
active
very active
Could you eat more healthy?
*
Yes
No
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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