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Diabetes review

Diabetes

Form summary

Have you been referred to a structured diabetes education programme in the last 9 months?

Eye screening

Have you had a retinal eye screening since your last review?
For example, 31/03/1980
Have you had any problems with your eyes since your last review? *
This may be a change in your vision or a new issue you have noticed

Foot screening

Have your feet been an abnormal colour since your last review? *
Have you noticed a change in the shape of your feet since your last review? *
Have you had any burning in your feet since your last review? *
Have you had any pain in your feet since your last review? *
Have you had any blisters on your feet since your last review? *
Have you had an open wound on your feet since your last review? *
For example, a cut or abrasion
Have you had any bunions on your feet since your last review? *

Injection therapy technique

Do you inject diabetes medication?
Do you have any concerns with your technique or the sites of the injections? *

Guidance is available on the Injection Technique Matters YouTube channel (opens in new tab)

Mental health and wellbeing

How much are you bothered by feeling overwhelmed by the demands of living with diabetes? *
On a scale of 1 to 2 being “not a problem”, 3 to 4 being “a moderate problem” or 5 to 6 being “a serious problem”
How much are you bothered by feeling that you are often failing with your diabetes regimen? *
On a scale of 1 to 2 being “not a problem”, 3 to 4 being “a moderate problem” or 5 to 6 being “a serious problem”

Blood glucose

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
Have you been asked to monitor your blood glucose levels by a doctor, nurse or other healthcare professional?
Are you able to provide 5 days of blood glucose readings?

Day 1

For example, 31/03/1980
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L

Day 2

For example, 31/03/1980
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L

Day 3

For example, 31/03/1980
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L

Day 4

For example, 31/03/1980
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L

Day 5

For example, 31/03/1980
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L

Alcohol consumption

Do you drink alcohol?
Units and calories for drinks
Type of drink Number of alcohol units
Single small shot of spirits (25ml, ABV 40%) 1 unit
Alcopop (275ml, ABV 5.5%) 1.5 units
Small glass of red/white/rosé wine (125ml, ABV 12%) 1.5 units
Bottle of lager/beer/cider (330ml, ABV 5%) 1.7 units
Can of lager/beer/cider (440ml, ABV 5.5%) 2.4 units
Pint of lower-strength lager/beer/cider (ABV 3.6%) 2 units
Standard glass of red/white/rosé wine (175ml, ABV 12%) 2.1 units
Pint of higher-strength lager/beer/cider (ABV 5.2%) 3 units
Large glass of red/white/rosé wine (250ml, ABV 12%) 3 units
For example, 2.5

Height and weight

For example, 1.75
For example, 60.6

Blood pressure reading

Are you able to provide a blood pressure reading?

When you’re taking your blood pressure at home there are things you can do to help get an accurate reading.

Try to:

  • sit on an upright chair with a back
  • place your feet flat on the floor
  • rest your arm on a table and relax your hand and arm
  • wear something with short sleeves so the cuff does not go over clothes
  • relax, breathe normally and do not talk during the test
  • take another reading a few minutes after your first reading to check it’s accurate

Watch how to measure your blood pressure at home (opens in new tab)

For example, 31/03/1980
mmHg
mmHg
/min

Smoking status

What is your smoking status? *

Smoker

What type of tobacco or other product do you use mostly? *
How many cigarettes do you smoke on an average day? *
How many cigars do you smoke on an average day? *

When you quit smoking, good things start to happen. You can begin to see almost immediate improvements to your health.

It’s never too late to quit and it’s easier to stop smoking with the right support.

Get help with NHS Quit Smoking (opens in new tab)

Would you like help to give up smoking? *

Ex-smoker

What type of tobacco or other product did you use mostly? *
How many cigarettes did you smoke on an average day? *
How many cigars did you smoke on an average day? *

More information

Is there anything you would like to discuss?
For example, your diabetes, lifestyle, medication, support
Terms and conditions