Diabetes Review

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

If you smoke, we strongly advise that you stop. If you would like help with this, please visit the Stop Smoking London website.

Diabetes Review

Diabetes Review

If you are human, leave this field blank.

About You

Full Name *

Date of Birth *

Please use this date format: DD/MM/YYYY.

Phone Number

Email Address *

Your Diabetes Review

Most Recent Blood Glucose Level

Total Cholesterol

Height

Weight

Do you smoke?

Yes

No

If you smoke, we strongly advise that you stop. If you would like help with this, please visit the Stop Smoking London website.

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:

*

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