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Bangholm Medical Centre

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Request an Appointment Online
Practice Forms
Request a Sickline
Send An Image
Become A Patient
Appointments
Prescription Requests
Mental Health Resources
Annual Birthday Reviews
Our Services
Vaccination Information
Health Advice
A-Z of Community Resources

Home
Language
Home
Meet The Team
Our Services
Health Advice
A-Z of Community Resources
Appointment Reminders
Contact Us

Diabetes Annual Review Form

Please fill in this form prior to your annual review appointment.

PLEASE NOTE- Section 2 is optional, however, completion of these questions would be helpful for our clinicians to review your health.

Last Updated: 17/10/2022

Your Details

Name: *

Date of Birth: *

THIS INFORMATION IS NOT COMPULSORY, BUT WILL AID OUR CLINICIANS TO REVIEW YOUR DIABETES

Are you a smoker?

Yes No

How many units of alcohol do you drink each week?

0 units

1-2 units

3-4 units

5-6 units

7+ units

Height

Weight

Your Diabetes

What type of diabetes do you have? *

Type 1

Type 2

Unsure

How long have you had diabetes? *

0-1 Years

1-5 Years

5+ Years

Are you taking your medication the same way it is prescribed on your repeat list? *

Yes

No

Do you require any alterations to amounts to improve re-ordering? (eg. tablets out of sync with others) *

Do you drive? *

Yes No

Do you test your blood sugar? *

Yes No

If you test your blood sugar, what are some of your recent levels?

Has your diet or lifestyle changed since your last appointment? *

Do you have anything you would like to speak to a GP about regarding your diabetes? *

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