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Personal Details

Height and Weight

Healthy Living Habits

How many units of alcohol do you drink each week? *

Do you smoke? *

Never smoked

Ex smoker

Trivial (less than one cigarette per day)

Light (1-9 cigarettes per day)

Moderate (10-19 cigarettes per day)

Heavy (20-39 cigarettes per day)

Very heavy (40+ cigarettes per day)

Cigar smoker

Pipe smoker

Mental Health

Chronic health conditions can increase the risk of mental health problems.

In the past month have you often been bothered by feeling down, depressed or hopeless? *

Yes No

In the past month have you often been bothered by little interest or pleasure in doing things? *

Yes No

Blood Pressure Readings

If you do not have a blood pressure monitor at home, your local pharmacy will be able to take readings for you.

Blood Sugar Reading

Foot Care

Diabetes makes you much more likely to develop problems with your feet – problems that could end up with ulcers and even amputations. Good foot care helps reduce the risk of developing serious problems.

Eye Care

Diabetes puts you at risk of serious eye problems. Diabetic retinopathy (damage to the retina) can cause sight loss and ultimately blindness. Diabetes also increases the risk of glaucoma and cataracts.

Medication

Hypoglycemia

Also known as 'hypo'. This is when your blood glucose level (also called blood sugar) is too low, usually below 4 mmol/l. This can happen if the balance of diabetes medication you take, food you eat and physical activity you do sometimes isn't right. Not everyone with diabetes will have hypos.

Diabetes Review Form

Further Information