Diabetes Review

Diabetes Review

Please note that you will be asked to provide your blood pressure, height and weight.

Please answer this section if you are completing the form on behalf of someone else.

About you (The patient)

Name  Required
Date of Birth  Required
Address  Required

About Your Diabetes

Have you had or have you booked your annual blood tests and urine check?  Required
Have you had a change in the sensation (feeling) in your feet since your last review?  RequiredThis includes numbness, pins and needles or tingling.
Has there been any breaks in the skin over your feet or legs since your last review?  Required
Have you been contacted (normally by letter) for your eye assessment (known as retinal screening)?  Required
Do you monitor your blood sugar levels?  Required
What are the approximate readings you have been getting?  Required
If you have a CURRENT reading of less than 4mmol/L, then this needs to be treated by following your action plan. If you are unsure, please contact your GP, diabetic nurse or 111 (if the practice is closed). If your CURRENT reading is greater than 11mmol/L, then this needs to be treated by following your action plan. If you are unsure, please contact your GP, diabetic nurse or 111 (if the practice is closed).
Do you know your blood pressure reading from the last month?  Required
For example: 120/80
Please indicate whether it is kg or stones
Please indicate whether it is cm or feet
In the last 12 months, have you had any hypoglycaemic episodes?  RequiredThese are episodes when your sugar levels become too low and you can feel unwell.
Please answer this section if you answered yes for the above question.
For example, forgetting to eat whilst continuing to take medication.
For example, in the morning, evening or overnight.
Have you been prescribed any medication(s) for your diabetes?  Required
Are there any medication(s) that you do not take?  Required
Does your diabetes affect your mental health?  Required
Please answer this section if you answered yes for the above question.
Please be aware that this will not be reviewed by a GP or clinician immediately. Therefore, if your matter is urgent, please contact the surgery directly.
Privacy Protection  Required

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