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Diabetes pre-review questionnaire

Diabetes Pre-Review Questionnaire

Section

Lifestyle

Please record your height, weight and waist measurement.

To correctly measure waist circumference:

  • Stand and place a tape measure around your middle, just above your hipbones.
  • Make sure the tape is horizontal around your waist.
  • Keep the tape snug around your waist, but not compressing the skin.
  • Measure your wasit just after you breath out.

For more information on how to measure your waist, please visit www.diabetes.org.uk.

Ft/in or cm
St/lb or kg
Inches or cm
Are you physically active?
How much physical activity do you get?

Alcohol Consumption

To calculate the number of units, please visit NHS: Calculating Alcohol Units or Drinkaware: Unit Calculator.

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day drinking?
Do you smoke?
Do you use an e-cigarette?
Would you like help to quit smoking?

For further information, please see NHS: Quit Smoking.

Blood Pressure

Please complete this section if you have a blood pressure monitor at home. Otherwise please leave this blank and skip to the next question.

Use the Home Blood Pressure Monitoring Diary to record all of your blood pressure readings. Please see the Home Blood Pressure Monitoring Explained leaflet for more information on how to take your blood pressure correctly at home and a diary sheet for recording your measurements.

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
Evening Measurement

Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
Evening Measurement

Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
Evening Measurement

Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
Evening Measurement

Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
Evening Measurement

Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
Evening Measurement

Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
Evening Measurement

Blood Glucose

Please complete this section if you have a blood glucose meter at home. Otherwise please leave this blank and skip to the next question.

This video may help if you are unsure about testing: Youtube: How To Test Blood Sugar, How To Use Glucometer, How To Check Blood Glucose.

Use My Blood Glucose Diary to record your blood glucose levels.

Day 1

Morning/Breakfast
Midday/Lunch
Evening/Dinner
Night/Pre-bed

Day 2

Morning/Breakfast
Midday/Lunch
Evening/Dinner
Night/Pre-bed

Day 3

Morning/Breakfast
Midday/Lunch
Evening/Dinner
Night/Pre-bed

Day 4

Morning/Breakfast
Midday/Lunch
Evening/Dinner
Night/Pre-bed

Day 5

Morning/Breakfast
Midday/Lunch
Evening/Dinner
Night/Pre-bed

Day 6

Morning/Breakfast
Midday/Lunch
Evening/Dinner
Night/Pre-bed

Day 7

Morning/Breakfast
Midday/Lunch
Evening/Dinner
Night/Pre-bed
Have you had any hypoglycaemic attacks where you have felt hungry, sweaty, shaky, tingly, dizzy, irritable, anxious or tired or have you recorded a blood glucose level of less than 4mmol/l?

Foot Check

The Touch the Toes test is a quick and easy test, designed to assess sensitivity in your feet, and can be done in the comfort of your own home.

The test involves lightly and briefly (1-2 seconds) touching the tips of the first, third and fifth toes of both feet with the index finger to detect a loss in sensation.

Instructions are available at Diabetes UK: Touch the Toes.

Did you feel the touch at all, six, or five of the six toes?
Are you experiencing any of the following?

Eyes

Have you attended your diabetic retinal screening appointment in the last year?

Complications / Hospital Admissions

Have you had any treatment or hospital admissions for diabetes-related complications in the preceding year eg angina/myocardial infarction, stroke/transient ischaemic attack (TIA), kidney problems, diabetic retinopathy, diabetic neuropathy or diabetes foot problems?
How is your mood?