Diabetes Review

If you have been advised by the surgery to submit an annual review of your diabetes symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Further Information:

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

Please provide a minimum of one blood pressure reading, up to a maximum of seven.

Day 1

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

Day 2

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

Day 3

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

Day 4

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

Day 5

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

Day 6

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

Day 7

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

Average Blood Pressure

This is automatically calculated for internal use only.

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

Injection Sites

Before submitting your review

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