Annual Diabetic Review Form

Please only complete the following questionnaire if requested by a member of our team as part of your routine diabetes review.

This questionnaire is for a routine review of your symptoms. If you are experiencing chest pain, severe shortness of breath or other concerning symptoms, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Diabetes home monitoring questionnaire V2
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979


My Last 3 home blood pressure recordings (mmHg)

Please go to the diabetic section for advice on how to measure blood pressure.

Lifestyle — Alcohol

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day drinking?

Lifestyle — Smoking

Do you smoke?
Do you use an e-cigarette?
Would you like help to quit smoking?
For further information please see NHS Smokefree


How much exercise do you get?
Do you follow a diabetic diet? i.e. low fat, low salt and low sugar
Have you attended your diabetic eye screening appointment? If not, you should have been sent a letter for the Retinopathy Screening Department, so please make sure you respond to this


If you drive a vehicle, please ensure that you comply with the DVLA regulations and Diabetes website advice in relation to testing blood sugar reading and with regards to hypoglycaemia.
Do you drive?


Frailty Score
How is your mood? *
How is your memory? *

Foot Care

Please indicate if you have
If you have any concerns relating to the above conditions please call the surgery for an appointment or make an appointment to see your Podiatrist/ Chiropodist
Do you have any leg swelling?
If yes, please telephone the surgery for further assessment if this swelling is new or getting considerably worse
Do you have painful legs when walking or at night?
If yes, please telephone the surgery for further assessment if this pain is new or getting considerably worse
Do you have any leg wounds?
If yes, please telephone the surgery for further assessment if this wound is new or getting considerably worse


Do you rotate your injection sites?
Are your injection sites lumpy?

Further Questions

Please see the following links for further information on cardiovascular disease that you may find useful:

NHS Diabetes Website

Diabetes UK Website

When you are happy with all your above answers, please click ‘Send’ below and the questionnaire will be automatically sent to your GP practice. Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

Privacy Policy

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.
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