Diabetes Review

I have:

Type 1 Diabetes

Type 2 Diabetes

Other

Please specify:

Year of diagnosis:

Current Medication:

Please include tablet(s) name/dose, Insulin name/dose via pen/syringe and needle/pump.

How do you monitor your diabetes?

Blood glucose monitor with testing strips

Glucose monitoring device e.g. Libre

Do you have a ketone monitor?

Yes

No

Please list monitors/lancets/testing strips you use:

Do you have a sharps bin?

Yes

No

Do you see a consultant regarding your diabetes?

Yes

No

Consultant name and/or hospital:

If your consultant is ‘at home’ would you like to transfer your care to Exeter?

Yes

No

Have you had/been referred for retinal (eye) screening?

Yes

No

Date of last blood test:

Date of last blood pressure check:

Date of last foot check:

St Thomas Medical Group