Diabetes Review

If you have been advised by the surgery to submit a 6 month review please use this form.

If you have any concerns please make an appointment with our Nurse.

Useful Information

Berkshire West Diabetes
Patient Info – Tests for Blood Sugar (Glucose) and HbA1c

Diabetes Review

Section

Your Diabetes Review

HbA1c

Total Cholesterol

Height

Weight

Do you smoke?

Yes

Blood Pressure

Heart Rate

Systolic "Higher"

Diastolic "Lower"

Date of your last Retinal Screening

Right eye

Left eye

Other Issues

Please let us know any issues you have with your diabetes or health in general:

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

I confirm that the information provided is accurate to the best of my knowledge.

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Useful Information

Diabetes Review

Section

Your Diabetes Review

Special Educational Needs and Disabilities