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Back Pain E-Visit Billing Question Blood Pressure Log Blood Sugar Readings Cold/Flu/Sinus/Cough//Throat/Respiratory Infection Comments or Suggestions Conjunctivitis/Pink Eye Depression Screening (PHQ9) Flu Shot Health Care Question HIPPA Hospitalization Insurance Change Form Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam New Patient Medical History New Patient Registration Form Password - Patient Request for Secure Password Patient Education Classes Prescription Refill Request Preventative Care Referral Question Specialist/ER/Hospital/Testing Update Specialist/Urgent Care or Hospital Visits Survey- Cary Adult Medicine Telemed Urinary Tract Infection Voluntary Alignment for Medicare ACO REACH Yeast Infection

Blood Pressure Log

Name

Date of Birth *

Approximate Date of Last Office Visit

Are you taking Blood Pressure Medication

Yes

No

Are you taking a new dose or a new blood pressure medication recommended at your last office visit

Yes

No

Please record your individual blood pressure readings below and include date . Example 2/12/12 BP 130/92

Blood Pressure / Date

Blood Pressure /Date

Blood Pressure / Date

Blood Pressure /Date

Blood Pressure / Date

Blood Pressure / Date

Blood Pressure/ Date

Blood Pressure / Date

Blood Pressure /Date

Blood Pressure/ Date

Blood Pressure/ Date

* Required field