Diabetes Review

Once you have completed and submitted this questionnaire, please contact the surgery to book an appointment for your blood test.

Please note you must bring a urine sample with you to this appointment.

You can self-refer to Oviva who deliver a remote, 1-1 specialised diabetes support education programme by visiting their website: www.oviva.com

Diabetes Review

Diabetes Review

Please use format DD/MM/YYYY

Are you tolerating your medication? *
Have you been referred to the podiatrist? *
Do you monitor your own blood pressure? *
Please use format DD/MM/YYYY
Please use format DD/MM/YYYY
Have you had a shingles vaccination? *
For men: Are you experiencing any erectile dysfunction?
Would you like to discuss having a referral to an educational course about your diabetes? *
Would you like to discuss referral to an exercise and weight management program (please note there would be ongoing cost involved after initial referral) *
Do you drive? *
Please confirm that if you are prescribed insulin you have informed the DVLA and are testing as required by their standards *

It is your responsibility as a driver to to make the DVLA and your insurance company aware of any medical condition you have. You can report your condition online at : www.gov.uk/diabetes-driving

If you have been issued a blood glucose monitor for oral diabetes medications that can cause hypoglycemia please confirm that you are testing your blood glucose within 2 hours prior to driving and after 2 hours if continuing to drive. *
Please indicate if you wish to discuss whether your medication is likely to cause lower blood glucose readings and affect your driving *
Please confirm you have read the information leaflets from the DVLA related to your diabetes and understand your legal obligations. *
How many units of Alcohol do you drink per week? *
Smoking Status: *

Mental Health Review

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Had little or no interest in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much *
Feeling tired, or having little energy *
Poor appetite or overeating *
Feeling bad about yourself - or that you are a failure or have let yourself or your family down *
Trouble concentrating on things, such as reading the newspaper or watching television *
Moving or speaking so slowly that other people have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual *
Thoughts that you would be better off dead or of hurting yourself in some way *
Social situations due to a fear of being embarrassed or making a fool of yourself *
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) *
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)
*