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Annual diabetic review

Annual Diabetic Review

Blood pressure recordings

Enter your last 3 home blood pressure recordings in mmHg.

How to measure blood pressure (opens in new tab)

mmHg
mmHg
mmHg

Height and weight

For example, 1.75
For example, 60.6

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? *

Smoking Status

Do you smoke?
Do you use an e-cigarette?
Would you like help to quit smoking?

Lifestyle

How much exercise do you get?
Do you follow a diabetic diet?
For example, low fat, low salt and low sugar
Have you attended your diabetic eye screening appointment?
If not, you should have been sent a letter for the Retinopathy Screening Department, so please make sure you respond to this

Driving

If you drive a vehicle, please ensure that you comply with the DVLA regulations and Diabetes website advice (opens in new tab) in relation to testing blood sugar reading and with regards to hypoglycaemia.

Do you drive?

Frailty

Clinical frailty scale:

  • 1. Very Fit: People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.
  • 2. Well: People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.
  • 3. Managing Well: People whose medical problems are well controlled, but are not regularly active beyond routine walking.
  • 4. Vulnerable: While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.
  • 5. Mildly Frail: These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.
  • 6. Moderately Frail: People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
  • 7. Severely Frail: Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within approximately 6 months).
  • 8. Very Severely Frail: Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
  • 9. Terminally Ill: Approaching the end of life. This category applies to people with a life expectancy less than 6 months, who are not otherwise evidently frail.
Select your frailty score:
How is your mood?
How is your memory?

Foot care

Please indicate if you have any foot problems:
If you have any concerns relating to these conditions, please call the surgery for an appointment or make an appointment to see your podiatrist / chiropodist
Do you have any leg swelling?
Please telephone the surgery for further assessment if this swelling is new or getting considerably worse
Do you have painful legs when walking or at night?
Please telephone the surgery for further assessment if this pain is new or getting considerably worse
Do you have any leg wounds?
Please telephone the surgery for further assessment if this wound is new or getting considerably worse

Medication

Do you rotate your injection sites?
Are your injection sites lumpy?

Further questions

Please see the following links for further information on cardiovascular disease that you may find useful:

When you are happy with all your above answers, please submit your form and the questionnaire will be automatically sent to us. Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

Terms and conditions