Diabetes review

First name: *

Last name: *

Date of birth: *

Email address: *

Phone number:

Do you stick to a diabetic diet? More information on diabetes and diet is available at

www.patient.info/type-2-diabetes-diet.

*

Yes

No

Please state why:

Do you have any problems with skin care, circulation or sensation in your feet? More information on diabetes and footcare is available at www.patient.info/diabetes-foot-care. *

Yes

No

Please state:

Have you been for diabetic retinopathy screening (eye photograph) in the last year? More information on diabetes and eyes is available at www.patient.info/diabetic-retinopathy. *

Yes

No

Please book an eye photograph by calling 01905 362780.

For men with diabetes: do you have any problems with weak erections during sex? *

Yes

No

Not relevant

Would you like to talk to a doctor about this?

Yes

No

For women between 15 and 50 with diabetes: diabetes and obesity cause a large increase in risks to mother and baby during pregnancy. The risk of miscarriage, still-birth, birth-defects and disability, difficult labour and other risks can be reduced by controlling diabetes before pregnancy. Would you like advice about planning a pregnancy? *

Yes

No

Not relevant

Do you drive? *

Yes

No

Please read the following information from the DVLA to make sure that you are driving legally and that your insurance is not invalidated: www.gov.uk/diabetes-driving.

There is a really good telephone-based diabetes education service in multiple languages. We highly recommend it. Please can we refer you to learn more about diabetes? *

Yes

No

Diabetes can be harder to control when you have another illness, like flu. Make sure you stay well hydrated. If you have a glucose meter please check your glucose more often. Continue eating as normally as possible. If you feel really unwell please don’t hesitate to contact us or 111. More information is available at www.patient.info/diabetes-and-illness. *

Please tick to say that you understand what to do if you get another illness.

Thanks for completing this form. Once you have completed your blood tests a doctor will be in touch to complete your review. When would be the best times for this appointment? *

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