Diabetes Review

Section

Patient Status

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Units per week
Do you smoke?
Would you like to be referred to a smoking cessation adviser?
Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.
Are you an ex smoker?
Please use date format DD/MM/YYYY.
Activity levels:

Review

Do you have annual influenza vaccination?
Have you ever had a pneumonia vaccine?
Have you been prescribed a blood glucose monitor?

Blood Sugar Readings

Please complete the following blood sugar readings for the last 2 weeks.

Before breakfast

Before lunch

Before evening

Before sleep

Text/Email Consent

The practice can send you a text message or email with your appointment time and appointment reminder. *

Summary Care Record

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. Please select one of the options below:

Consent:

Are you sure? If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill.