Diabetes Review

Please complete this form to help your Nurse to assist you with reviewing your diabetes.
If you are experiencing symptoms and have concerns about your diabetes, please contact the surgery to arrange an appointment to see the Diabetic Nurse.
Name*
First Last
Date of birth*
MM slash DD slash YYYY
Phone
Email*
Home Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Name of GP
Gender
- Male
- Female
What is your current blood pressure reading? (Systolic)*
What is your current blood pressure reading? (Diastolic)*
What is your current pulse rate (beats/minute)?*
What is your current weight?*
What is your most recent blood glucose level?*
What is your most recent total cholesterol level?*
When did you last have your eyes tested at the hospital for Retinal screening?*
MM slash DD slash YYYY
If you have any concerns or issues about your diabetes, please provide details below.*
I confirm that the information provided is accurate to the best of my knowledge*
- Confirm
Name
This field is for validation purposes and should be left unchanged.