Diabetes review

Full Name

Date of Birth

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

Phone Number

Email Address

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.

Heart Rate

Systolic “Higher”

Diastolic “Lower”

Right eye

Left eye

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.

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