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Bangholm Medical Centre

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

Home
Language
Home
Meet The Team
Our Services
Health Advice
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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