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
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 have any questions or problems relating to your diabetic medications, if you are taking any?
If you inject insulin, how many times do you do this a day?
Do you rotate your injection sites?
Are your injection sites lumpy?
If you test your blood glucose levels at home what have your recent glucose levels been? Please specify dates and times:
Please specify how much insulin you inject and at what times or if you carbohydrate count?
I have the following information, questions or concerns that I would like to raise with my Nurse or Doctor
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.
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
to discover how we protect and manage your submitted data.