Diabetes Review

Have you received a letter, text message or verbal invitation to complete this assessment? *

Your Health Information

Unit of measurement: *
Unit of measurement: *
Unit of measurement: *
Smoking status: *
Would you like advice to help quit smoking?

Alcohol Review

This is one unit of alcohol:

And each one of these, is more than one unit:

How many units of alcohol do you drink on a typical day when you are drinking? *

Your Blood Pressure

If unable to complete using your own home blood pressure monitor, then please phone reception to book in to use the blood pressure machine in our waiting room.

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Do you take insulin or other medication that requires you to test your blood sugars regularly? *

Blood Sugar Readings Day 1

Blood Sugar Readings Day 2

Blood Sugar Readings Day 3

Blood Sugar Readings Day 4

Blood Sugar Readings Day 5

Current Medication

Please select one of the following: *

Diabetic Review

I have had my diabetic eye test in the last year *
I have concerns about sensation, pain or ulcers in my feet *
I have booked/had an appointment for a blood test *
I have provided a urine sample to check my kidneys *
I would like more written information on diabetic diet and lifestyle *
I would like to be referred to a diabetes education programme *

Diabetes UK: Driving when you have diabetes

For patients on Gliclizide or Insulin only

I have a working monitor and test strips
I am aware the symptoms of low blood sugar
I feel confident managing my blood sugar if it goes low

Injection Sites

Before submitting your review

Do you have any concerns you need to discuss? *
*