Name Date of Birth * Choose your medical practice Choose your provider Approximate Date of Last Office Visit Are you taking Blood Pressure Medication Are you taking a new dose or a new blood pressure medication recommended at your last office visit

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