Annual Diabetes Review Questionnaire

Only complete this form if instructed to by a member of staff

Please do not complete this form unless the surgery has asked you to do so.

You are due an annual diabetes review.

Please answer the questions in the form below and submit it to the surgery.

About you

Full Name

Date of Birth

Address and Postcode

NHS Number (optional)

Preferred Contact Details (email or phone)

Questionnaire

Have you ever smoked?

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If you still smoke, how many do you smoke each day?

If you have quit smoking, when did you quit?

How much alcohol do you consume?

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

Do you know your up to date Blood Pressure ( systolic / diastolic)?

Do you know you Resting Pulse (beats per minute)?

Do you know your BMI?