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Newpark Surgery
Gwaunmiskin Road Surgery
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Diabetic Annual Review
Please fill in the form below to complete your online Diabetic review. Please fill this in prior to your appointment with the nurse. This form is not to be used instead of seeing the nurse.
First name
Last name
Birthday
Address
Email
Phone
Have you had or have you booked your annual blood tests and urine check?
Choose an option
Have you had a change in the sensation (feeling) in your feet since your last review?
Choose an option
Has there been any breaks in the skin over your feet or legs since your last review?
Choose an option
Have you been contacted (normally by letter) for your eye assessment (known as retinal screening)?
Choose an option
Do you monitor your blood sugar levels?
Choose an option
If you know your blood sugars, what are the approximate readings you have been getting?
Choose an option
Please provide your average blood pressure readings
What is your height?
What is your weight?
In the last 12 months, have you had any hypoglycaemic episodes?
Choose an option
Have you been prescribed medication for your diabetes?
Choose an option
As a diabetic patient you are entitled to your annual flu vaccine and a one off pneumococcal vaccination.
Choose an option
Are you aware of the guidance for diabetes and driving? The updated DVLA guidance will be emailed to you after completing this form
Choose an option
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