Diabetes Review

Please complete this form prior to your appointment.

Diabetes Review
Please complete this form prior to your appointment.

Section

Lifestyle Questionnaire, Home BP Readings and Pulse

Please indicate KG, Stone, Lb.
Please measure around your waist.
How physically active are you? *
Do you smoke? *
Would you like support to stop smoking? *
Please specify units if you can
Are you happy for us to use the above email address to send you future letters from the surgery? *

Blood Pressure Readings

Please complete for one week ahead of your appointment.

The systolic is the higher number which is given first or on top, the diastolic is the lower number which is given 2nd or below.

Your pulse is usually the final number on the screen.

Day 1

Please use this date format: DD/MM/YYYY.

Day 2

Please use this date format: DD/MM/YYYY.

Day 3

Please use this date format: DD/MM/YYYY.

Day 4

Please use this date format: DD/MM/YYYY.

Day 5

Please use this date format: DD/MM/YYYY.

Day 6

Please use this date format: DD/MM/YYYY.

Day 7

Please use this date format: DD/MM/YYYY.