Patient code (example: K12345) *

Have you received from us

Data protection is very important to us, therefore medical and personal data is only sent in encrypted form. For additional protection, we ask you not to enter any data that can be traced back to you. The patient code allows us to assign the sent data to your file.

Date and time of the measurement

Date

Time

Systolic *

This is the higher value (Systolic)

Diastolic *

This is the lower value (diastolic)

Heart rate *

Heart rate / Heart rate

Weight in kg

Please weigh every time in the clinic

Drug changed / reduced? *

Yes
No

What medication was changed / reduced? *