Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Home Blood Pressure Report Form Template

Track Your Blood Pressure Readings with Ease

Keeping track of your blood pressure can feel overwhelming, especially if you have to manage multiple readings over time. This Home Blood Pressure Report Form Template is designed to help you easily record your readings for effective monitoring and management. You'll benefit from a structured way to document trends, share your data with healthcare providers, and stay on top of your health goals, all while ensuring your records are organized and accessible. You can start using this live template today to take control of your health tracking.

Use this Template (FREE) Live Preview
Full name
Email address
What is your age group?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Monitoring period start date
Monitoring period end date
Typical number of readings per day
1 per day
2 per day
3 per day
More than 3 per day
Where is your blood pressure monitor placed when measuring?
Upper arm
Wrist
Finger
Other
Please Specify:
Device brand and model
Cuff size
Small
Medium
Large
Extra large
Not sure
When was your device last validated or calibrated?
Within the past 1 year
1-2 years ago
More than 2 years ago
Never/Not sure
Measurement posture used most often
Sitting
Standing
Lying down
Other
Please Specify:
Which arm was used most often?
Left arm
Right arm
Both equally
Not sure
Before and during measurements, which practices did you usually follow?
Morning average systolic (mmHg)
Morning average diastolic (mmHg)
Evening average systolic (mmHg)
Evening average diastolic (mmHg)
Highest single reading during this period (e.g., 160/100)
Additional notes on your readings (optional)
Did you record any single reading at or above 180/120 mmHg?
Yes
No
Current blood pressure medications (name and dose)
Were there any medication changes during the monitoring period?
Yes
No
If medications changed, what was the change date?
Do any of the following apply to you?
Diabetes
Chronic kidney disease
Heart disease or prior stroke/TIA
Pregnancy
Sleep apnea
None of the above
Prefer not to say
During the monitoring period, did you experience any of the following symptoms?
Headache
Dizziness or lightheadedness
Vision changes
Chest pain or pressure
Shortness of breath
Nosebleed
Swelling in legs or ankles
None of the above
Who should receive this report? (clinician name or practice)
Signer full name
Sign date
I confirm the information is accurate to the best of my knowledge and I consent to share this report with my healthcare provider.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
What follow-up would you like?
Review and message me with recommendations
Schedule a phone call
Schedule an in-person visit
No follow-up needed
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Email address, What is your age group?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a home blood pressure report form template design for FormCreatorAI

When to use this form

Use this form when you or a patient tracks blood pressure at home between visits. It helps people with hypertension, pregnancy monitoring, or new medication starts capture consistent readings and notes. Share it before telehealth check-ins, after a medication change, or during a 7-day monitoring plan. Clinicians can import summaries into the record and spot trends, white-coat effects, or missed doses. For a fuller picture at visits, pair it with a Medical assessment form or a General health appraisal form. The result: clear, time-stamped data that guides treatment, reduces guesswork, and supports safer medication titration.

Must Ask Home Blood Pressure Report Questions

  1. What is the date and time of each reading?

    Time of day affects blood pressure and shows medication peaks or missed doses. Timestamps let you compare morning and evening patterns and guide dosing decisions.

  2. What are the systolic and diastolic numbers, and your pulse?

    These core values show control level and heart workload. Including pulse helps spot irregular rhythms and stress responses.

  3. Which arm did you use, and what was your body position?

    Arm choice and position (sitting, feet flat, back supported) can change results by 5 to 10 mmHg. Recording this keeps readings consistent and comparable over time.

  4. Did you rest 5 minutes and avoid caffeine, smoking, or exercise 30 minutes before?

    Pre-reading steps prevent false highs. This confirms the reading follows best practice and can be trusted for treatment changes.

  5. What medications did you take today, and did you have any symptoms?

    Drugs, missed doses, headache, chest pain, or shortness of breath can explain outliers and prompt action. If you note vision changes, numbness, or severe headache, the Neurological exam form helps capture those details for follow-up.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel