Diabetes Review Questionnaire Name First Last Date of Birth PhoneDiabetes ReviewThis questionnaire is for a routine review of your symptoms. If you are experiencing chest pain, severe shortness of breath or other concerning symptoms, please follow your care plan (if you have one) or ring your GP or 999 immediately Your Diabetes Review QuestionsHave you attended a diabetes structure education programme in the last year? Yes – Attended diabetes structured education programme in the last year Yes – Attended diabetes structured education programme in the last year but did not complete this. No – Have previously attended diabetes structured education though but not in the last year No – Did not attend diabetes structured education programme No – Declined to attend diabetes structured education programme Have you attended your diabetic eye screening appointment? If no, you should have been sent a letter for the Retinopathy Screening Department, so please make sure you respond to this Yes – I have attended my diabetic eye screening in the last year No – I have not attended my diabetic eye screening in the last year Have you had any hypoglycaemic attacks where you have felt hungry, sweaty, shaky, tingly, dizzy, irritated, anxious, tired? If yes, please telephone the surgery for further assessment if this is new or getting worse No – No significant hypoglycaemic attacks No – No significant hypoglycaemic attacks requiring outside help Yes – Significant hypoglycaemic attacks Yes – Significant hypoglycaemic attacks requiring outside help If you use any injectable medications, please check your injection sites and select one of the options below. If abnormal, please telephone the surgery for further assessment if this is new or getting worse Injection sites – Checked and normal Injectable sites – Checked and abnormal Injectable sites – not checked Are you having any chest pain? If yes, please telephone the surgery immediately (or phone 999 if necessary) for further assessment No – No chest pain present Yes – Chest pain present Are you having any shortness of breath? If yes and severe, please telephone the surgery immediately (or phone 999 if necessary) for further assessment No – No breathelessness Yes – Breathlessness on mild exertion Yes – Breathlessness on moderate excertion Yes – Breathlessness on strenuous exertion Do you have any leg swelling? If yes, please telephone the surgery for further assessment if this swelling is new or getting considerably worse No – No foot, ankle or leg swelling Yes – Swelling of feet only Yes – Swelling of ankles Yes – Swelling of legs Do you have painful legs when walking or at night? If yes, please telephone the surgery for further assessment if this pain is new or getting considerably worse No – No pain in legs when walking or at rest at night in bed Yes – Painful ache in legs when walking that gets better with rest Yes – Painful ache in legs in bed at night that gets better on standing Yes – Painful ache in legs when walking and in bed at night Do you have any leg wounds? If yes, please telephone the surgery for further assessment if this wound is new or getting considerably worse No – No leg wounds Yes – Leg wounds but healing well Yes – Leg wounds but healing badly Your Lifestyle – Alcohol How often do you a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 times or more a week How many units of alcohol do you drink on a typical day drinking? Please see: https://www.drinkaware.co.uk/understand-your-drinking/unit-calculator 1-2 3-4 5-6 7-9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily of almost daily Your Lifestyle – Activity & Diet How much exercise do you get? I get no exercise I enjoy light exercise I enjoy moderate exercise I enjoy heavy exercise Exercise is physically impossible for me What is your diet like? My diet is average My diet is good My diet is poor I am on a weight reducing diet I am a vegan Post Custom Field Optional Comments OptionalThis field is for validation purposes and should be left unchanged.