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:

• www.diabetes.org.uk
• www.dietdoctor.com
• www.lowcarbprogram.com
• trend-uk.org

Diabetes Review

If you are human, leave this field blank.

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

Yes

No

Patient ID: *

Your Health Information

Weight: *

Unit of measurement: *

KG

Stone, Pounds

Height: *

Unit of measurement: *

CM

Feet/Inches

Waist Circumference: *

Unit of measurement: *

CM

Inches

Are you taking any over the counter medication such as vitamin supplements or pain relief? Please give detail: *

Smoking status: *

Smoker

Ex Smoker

Never Smoked

How many do you smoke per day?

Would you like advice to help quit smoking?

Yes

No

How many did you smoke per day?

When did you 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? *

N/A

1-2

3-4

5-6

7-9

10+

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.

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher" *

/

Diastolic "Lower" *

Heart Rate *

Evening Measurement

Systolic "Higher" *

/

Diastolic "Lower" *

Heart Rate *

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

Yes

No

Blood Sugar Readings Day 1

Pre - Breakfast:

Post - Breakfast:

Pre - Lunch:

Post - Lunch:

Pre - Evening Meal

Post Evening - Meal:

Pre - Bedtime:

Blood Sugar Readings Day 2

Pre - Breakfast:

Post - Breakfast:

Pre - Lunch:

Post - Lunch:

Pre - Evening Meal

Post Evening - Meal:

Pre - Bedtime:

Blood Sugar Readings Day 3

Pre - Breakfast:

Post - Breakfast:

Pre - Lunch:

Post - Lunch:

Pre - Evening Meal

Post Evening - Meal:

Pre - Bedtime:

Blood Sugar Readings Day 4

Pre - Breakfast:

Post - Breakfast:

Pre - Lunch:

Post - Lunch:

Pre - Evening Meal

Post Evening - Meal:

Pre - Bedtime:

Blood Sugar Readings Day 5

Pre - Breakfast:

Post - Breakfast:

Pre - Lunch:

Post - Lunch:

Pre - Evening Meal

Post Evening - Meal:

Pre - Bedtime:

Current Medication

Please select one of the following: *

I am not currently prescribed any diabetic medication

I am prescribed medication, understand what it is for and feel it suits me well

I am prescribed medication but do not understand why or feel it may need review

I have stopped taking some or all of my medication due to concerns about it

I am under the hospital for my diabetes reviews

Date of last review:

Diabetic Review

I have had my diabetic eye test in the last year *

Yes

No

I have concerns about sensation, pain or ulcers in my feet *

Yes

No

I have booked/had an appointment for a blood test *

Yes

No

I have provided a urine sample to check my kidneys *

Yes

No

I would like more written information on diabetic diet and lifestyle *

Yes

No

I would like to be referred to a diabetes education programme *

Yes

No

Diabetes UK: Driving when you have diabetes

I confirm that I have read the information about diabetes and driving and understand how this applies to me

For patients on Gliclizide or Insulin only

I have a working monitor and test strips

Yes

No

I am aware the symptoms of low blood sugar

Yes

No

I feel confident managing my blood sugar if it goes low

Yes

No

How many times have you had to correct your blood sugar due to it being low in the last month?

Injection Sites

Please detail any problems with where you inject, for example any bruises lumps or swelling: *

Before submitting your review

Do you have any concerns you need to discuss? *

Yes

No

Please specify:

*

I confirm that the information provided is accurate to the best of my knowledge

Submit