Diabetes Review

Patient Details

Full Name: *

Date of Birth: *

Please use date format: DD/MM/YYYY

Phone Number: *

Email Address: *

BMI

Height (in Meters) *

e.g 1.75

Weight (in Kilograms) *

e.g 60.6

BMI:

Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure

Please give your 7 latest home Blood Pressure readings.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Time of day for measurement:

Systolic “Higher”

/

Diastolic “Lower”

Time of day for measurement:

Systolic “Higher”

/

Diastolic “Lower”

Time of day for measurement:

Systolic “Higher”

/

Diastolic “Lower”

Time of day for measurement:

Systolic “Higher”

/

Diastolic “Lower”

Time of day for measurement:

Systolic “Higher”

/

Diastolic “Lower”

Time of day for measurement:

Systolic “Higher”

/

Diastolic “Lower”

Time of day for measurement:

Systolic “Higher”

/

Diastolic “Lower”

This is automatically calculated for internal use only.

Systolic “Higher”

/

Diastolic “Lower”

Smoking

Smoking status: *

Smoker

Never smoked

Ex smoker

Smoker

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week? *

Pipe – How many grams of tobacco do you smoke per week? *

Would you like help to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

When did you give up smoking? *

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Eye Screening

What was the date of your retinal eye screening or hospital eye clinic appointment?

Please use date format DD/MM/YYYY.

Have you noticed any change in vision or developed eye problems since your last diabetes review? *

Yes

No

Foot Screening

Since your last review, have you had any of the following foot problems?

Current abnormal foot colour: *

Currently

In the last year

None

Change of foot shape: *

Currently

In the last year

None

Burning: *

Currently

In the last year

None

Pain: *

Currently

In the last year

None

Blisters: *

Currently

In the last year

None

Open wound (e.g. cut, abrasion): *

Currently

In the last year

None

Bunions: *

Currently

In the last year

None

Any other problems (including if the problem is current or in the last year):

The ‘Touch the Toes Test’ is a quick and easy way to assess sensitivity in your feet, and can be done in the comfort of your own home, with the help of a family member or carer to perform the test.

How to complete the test and advice (opens in new tab)

Record your results for each toe by answering the following questions, if you are able to.

Blood Glucose Readings

If you have been asked to monitor blood glucose levels by your GP or nurse please can you enter any readings you have recorded over the past 5 days into this diary.

Day 1

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 2

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 3

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 4

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

Day 5

Date:

Please use date format: DD/MM/YYYY

Before breakfast:

2 Hours after breakfast:

Before lunch:

2 Hours after lunch:

Before dinner:

2 Hours after dinner:

Before Bed:

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.

Yes

No

(1 being always aware and 7 being never aware)

Injection Therapy Technique

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

Yes

No

Guidance is available at Injection Technique Matters Youtube Channel.

Mental Health and Wellbeing

Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. Listed below are 2 potential problem areas that people with diabetes may experience. Consider the degree to which each of the 2 items may have distressed or bothered you during the past month and select the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, not whether the item is merely true for you. If you feel that a particular item is not a bother or a problem for you, you would select “1” If it is very bothersome to you, you might select “6”

Feeling

Please indicate the level of the problem by using the 1-6 scale (1-2 being not a problem / 3-4 being a moderate problem / 5-6 being a serious problem):

Feeling overwhelmed by the demands of living with diabetes:

(1-2 being not a problem / 3-4 being a moderate problem / 5-6 being a serious problem)

Feeling that I am often failing with my diabetes regimen:

(1-2 being not a problem / 3-4 being a moderate problem / 5-6 being a serious problem)

Your Diabetes Priority Areas

These are some things that people sometimes want to talk about. Please select any that are important to you.

More Information

Is there anything specific you would like to discuss at your diabetes review? *

Yes

No

Please specify: *

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Patient Details

BMI

Blood Pressure

Smoking

Smoker

Ex Smoker

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

Eye Screening

Foot Screening

Blood Glucose Readings

Day 1

Day 2

Day 3

Day 4

Day 5

Injection Therapy Technique

Mental Health and Wellbeing

Feeling

Your Diabetes Priority Areas

More Information