Diabetes Review

Your GP practice is still here to support you with your diabetes during the COVID-19 pandemic. Do not hesitate to contact us or the 111 service if you become unwell or need urgent advice.

To prepare for, or to request a remote diabetes review please complete the questions on this form. This will allow our clinical team to offer you the best advice specific to your health needs.

Diabetes Questionnaire

BMI

e.g 1.75
e.g 60.6
Please note: BMI calculator is only for patients aged 18 and over.

BMI: Underweight Find out what this means for you on the NHS Website.

BMI: Healthy Weight Find out what this means for you on the NHS Website.

BMI: Overweight Find out what this means for you on the NHS Website.

BMI: Obese Find out what this means for you at NHS Website.

Blood Pressure

Please give your 7 latest home Blood Pressure readings:
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This is automatically calculated for internal use only.

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Smoking Status

Please select your smoking status: *
Would you like to arrange an appointment for smoking cessation advice? *

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

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

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Exercise

Are you physically active? *

Diet

How would you describe your diet? *

Eye Screening

Please use date format DD/MM/YYYY.
Have you noticed any change in vision or developed eye problems since your last diabetes review? *

Foot Screening

Please use date format DD/MM/YYYY.
Have you noticed any change of foot colour or shape, burning, pain, or skin lesions such as blisters, cuts, bunions, or other skin damage since your last diabetes review? *
Does anything worry you about the condition of your feet? *

If you have diabetes and lose some feeling in your feet, you may not feel that you've been hurt. That could mean it's not treated quickly enough which could lead to serious infections or ulcers. In the worst cases, it leads to amputation. Maybe you know that you have less sensation in some parts of your feet. In this case, you need to check your feet every day by looking over them.

Blood Glucose Readings

If you have been asked to monitor blood glucose levels by your GP or nurse please can you enter any readings you have recorded over the past 5 days into this diary.

Day 1

Please use date format: DD/MM/YYYY

Day 2

Please use date format: DD/MM/YYYY

Day 3

Please use date format: DD/MM/YYYY

Day 4

Please use date format: DD/MM/YYYY

Day 5

Please use date format: DD/MM/YYYY
Have you experienced any symptoms of hypoglycaemia? This is defined as a blood glucose level below 4 mmol, although some patients experience symptoms when blood glucose levels are higher than this..
Do you know when your hypos are commencing? *
1 being always aware and 7 being never aware.

Injection Therapy Technique

If you inject diabetes medication do you have any concerns with your technique or the sites of the injections?

More Information

Did you have a flu vaccination last flu season? *
Do you know how to manage your diabetes when unwell? *
Do you feel you have any problems with your medication? *
I consent to receive a SMS response from the nurse (if required) *