Diabetes Questionnaire

If you have been advised by the practice to complete a diabetes questionnaire, please submit this form. This will allow our clinical team to offer you the best advice specific to your health needs.

If we consider that it is important to have a blood or urine test before this review appointment, we will advise you in advance.

Diabetes Questionnaire

Diabetes Questionnaire

BMI

e.g 1.75
e.g 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure

Please give your 7 latest home Blood Pressure readings:

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This is automatically calculated for internal use only.

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Smoking Status

Please select your smoking status: *
How many cigarettes did you smoke in a day?
How many cigarettes do you smoke in a day?
Would you like help to give up smoking?

If you would like help or advice to quit smoking, please visit our Wellbeing Centre.

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 alcoholAmount 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? *

Diet and Activity

What is your diet like?
How much exercise do you get?

Eye Screening

Please use date format DD/MM/YYYY.
Have you noticed any change in vision or developed eye problems since your last diabetes review? *

Foot Screening

Have you noticed any change of foot colour or shape, burning, pain, or skin lesions such as blisters, cuts, bunions, or other skin damage since your last diabetes review? *

If you have diabetes and lose some feeling in your feet, you may not feel that you've been hurt. That could mean it's not treated quickly enough which could lead to serious infections or ulcers. In the worst cases, it leads to amputation. Maybe you know that you have less sensation in some parts of your feet? In this case, you need to check your feet every day by looking over them.

Please complete a 'Touch the Toes Test' which 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. Please view the Diabetes UK document for instructions: Diabetes UK: Touch the toes test.

Please record your results below:

Touch the toes test

Touch the toes test left foot

Right Foot:
Left Foot:

Leg Swelling

Do you have any leg swelling?

Please telephone the surgery on 01692 403015 for further assessment if this swelling is new or getting considerably worse.

Painful Legs

Do you have painful legs when walking or at night?

Please telephone the surgery on 01692 403015 for further assessment if this pain is new or getting considerably worse.

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

Please use date format: DD/MM/YYYY

Day 2

Please use date format: DD/MM/YYYY

Day 3

Please use date format: DD/MM/YYYY

Day 4

Please use date format: DD/MM/YYYY

Day 5

Please use date format: DD/MM/YYYY

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.
Do you know when your hypos are commencing? *

(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?

Guidance is available at Injection Technique Matters Youtube Channel.

Chest Pain

Are you having any chest pains?

Please telephone the surgery on 01692 403015 immediately (or phone 999 if necessary) for further assessment.

Shortness of Breath

Are you having any shortness of breath?

If severe, please telephone the surgery on 01692 403015 immediately (or phone 999 if necessary) for further assessment.

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)

Mood and Memory

How is your mood?
How is your memory?

Medication

Structured Education

Have you attended a diabetes structure education programme in the last year?

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? *