Diabetes Review Form

As part of our commitment to the care of your diabetes we would ask you to complete this questionnaire along with the annual medication review form prior to booking your appointment for a face to face review.

Last Updated: 06/04/2021

Patient Details

Name *

Date of Birth *

Contact Number *

Email Address *

Care of your diabetes

Please answer the following questions to see how your condition impacts on your daily life and how well controlled your condition is.

Foot care

Erectile Disfunction (Men only)

Do you suffer from erectile disfunction?

Yes - occational problems

Yes

If yes, are you taking any medication for the problem either prescribed by us or that you buy from the pharmacy or online?

Yes No

Flu Jab and your annual review

People with diabetes are at high risk of complications with flu (influenza) and are therefore entitled to the annual flu vaccination. They are available from the end of Oct each year.

I have had or will have my flu jab this year? *

Yes No

Have you had your annual blood tests for your diabetes? *

Yes

Appointment for blood tests booked

Have you had your annual urine test for your diabetes? *

Yes, I have already submitted a urine sample

No, but I will bring a sample to my review appointment

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form

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Diabetes Review Form

Further Information