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.

Please ensure you check your Spam/Junk email folder for any replies. An appointment/reply will be sent back to you via an email.

Diabetes Questionnaire

If you are human, leave this field blank.

Have you been asked by the practice to complete this online review form? *

Yes

No

Please do not fill this form in until you have been asked to complete it by the GP surgery. If you have not been asked to submit this form, you will need to discuss it with the surgery first.

BMI

Height (in Meters) *

e.g 1.75

Weight (in Kilograms) *

e.g 60.6

BMI:

Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure

Please give your 7 latest home Blood Pressure readings:

Time of day for measurement:

Systolic "Higher"

/

Diastolic "Lower"

Time of day for measurement:

Systolic "Higher"

/

Diastolic "Lower"

Time of day for measurement:

Systolic "Higher"

/

Diastolic "Lower"

Time of day for measurement:

Systolic "Higher"

/

Diastolic "Lower"

Time of day for measurement:

Systolic "Higher"

/

Diastolic "Lower"

Time of day for measurement:

Systolic "Higher"

/

Diastolic "Lower"

Time of day for measurement:

Systolic "Higher"

/

Diastolic "Lower"

This is automatically calculated for internal use only.

Systolic "Higher"

/

Diastolic "Lower"

Smoking Status

Please select your smoking status: *

Current Smoker

Ex-Smoker

Never Smoked

Would you like to arrange an appointment for smoking cessation advice? *

Yes

No

Alcohol Consumption

This is one unit of alcohol:

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

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Exercise

Are you physically active? *

Yes

No

What stops you being physically active? *

How many times a week do you manage to undertake structured exercise? *

Diet

How would you describe a healthy diet? *

How would you describe your diet? *

Good/healthy

Balanced

Poor

Eye Screening

What was the date of your retinal eye screening or hospital eye clinic appointment?

Please use date format DD/MM/YYYY.

Have you noticed any change in vision or developed eye problems since your last diabetes review? *

Yes

No

Foot Screening

When was the last time you checked your feet? *

Please use date format DD/MM/YYYY.

How often do you check your feet? *

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? *

Yes

No

Does anything worry you about the condition of your feet? *

Yes

No

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

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 2

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 3

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 4

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 5

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

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..

Yes

No

Do you know when your hypos are commencing? *

1

2

3

4

5

6

7

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?

Yes

No

Guidance is available at Injection Technique Matters Youtube Channel.

More Information

Did you have a flu vaccination last flu season? *

Yes

No

Do you know how to manage your diabetes when unwell? *

Yes

No

Do you feel you have any problems with your medication? *

Yes

No

Please specify:

Please add any further comments here (if you are planning a pregnancy then please request to speak to the triage nurse/GP):

I consent to receive a SMS response from the nurse (if required) *

Yes

No

Submit