Diabetic Review

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

Please only complete this form if asked to by a clinician.

Diabetic Review

Diabetic Review

Blood Pressure

Please give your latest home Blood Pressure reading:

/

BMI

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

Smoking Status

Please select your smoking status: *
What do you smoke? *

Your Doctor recommends that you quit smoking. To start today or for more information about the free stop smoking service visit NHS Smokefree.

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 alcohol
Amount 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? *

Your Feet

Have you ever had a foot ulcer? *
Have you seen any cuts or blisters that you didn’t feel? *
If you do have pain, does anything help it?
Can you cut your own nails? *

Touch the Toes Test

Please complete a ‘Touch the Toes Test’ which is a quick and easy way to assess sensitivity in your feet, and can be done in the comfort of your own home, with the help of a family member or carer to perform the test. Please view the Diabetes UK document for instructions: Diabetes UK: Touch the Toes Test.

Please record your results below:

Touch the toes test

Touch the toes test left foot

Right Foot:
Left Foot:

Your Medication

Are you happy with the medication you are on?
Do you take your medication as instructed?

General Information

Are you up to date with your diabetic eye screening? *
Would you be interested in the XPERT course which is designed to help you, re. diet and exercise? *
Have you been admitted to hospital due to issues with your diabetes? *
Would you like to give any further information? *

Depending on the information you have provided, we will only contact you if further action is required. If you take medication, this will be reviewed to ensure that you are taking the tablets most suited to you. Your repeat medication will then be updated, so that you can continue to get your tablets via your nominated pharmacy.