Blood Pressure Questionnaire

Name

First NameLast Name

Date of Birth

Date

When were you first diagnosed with raised blood pressure?

Do you know what your blood pressure was at that time?

If Yes, Pls provide details.

When did you last have your blood pressure measured?

Do you know what your blood pressure was on this occasion?

If Yes, Pls provide details.

Do you currently take any medication to lower your blood pressure?

If yes, please provide details:

Rows	Name of medication or treatment	Dose	Frequency	When did you stop taking this?

6 Other than already stated above, have you ever taken any other medicationto lower your blood pressure?

If yes, please provide details:

Rows	Name of medication or treatment	Dose	Frequency	When did you stop taking this?

Have you ever had any related tests or investigations e.g. blood test, 24 hourblood pressure recording, electrocardiograph, echocardiograph, urine test

If yes, please provide details:

Rows	Name of test or investigatioin	Location	Date	Results

Do you suffer from any related problems e.g. raised cholesterol, diabetesmellitus, heart, kidney or eye problems?

If Yes, Pls provide details.

Other than regular monitoring of your blood pressure, has any future treatmentor investigation been discussed or contemplated?

If Yes, Pls provide details.

Please provide the name and address of the doctors and/or specialists you have seen in relation to your raised blood pressure.

Rows	Name of doctor, hospital or clinic	Address	Date of last consult

Please provide any additional information that you feel is important:

I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any material information that may influence the assessment or acceptance of this application.

I agree that this form will constitute part of my application for insurance(s) and that failure to disclose any material fact known to me may invalidate my insurance(s).

Signature

Name

Date

Blood Pressure Questionnaire

Declaration