Diabetic Review

If you have been advised by the surgery to submit a diabetic review, please use this form. However, if your diabetes is not under usual control, please contact the surgery to make an appointment with your doctor.

Useful websites for more information about diabetes:

• www.xperthealth.org.uk
• www.diabetes.org.uk
• NHS Diabetes
• www.carbsandcals.com

Diabetic Review

Diabetic Review

If you are human, leave this field blank.

About You

First Name: *

Surname: *

Date of Birth: *

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

Phone Number:

Email Address: *

Blood Glucose Readings

Please complete the form below with readings as appropriate. Not all columns need to be filled in, your diabetes nurse can advise you how often these should be done.

Day 1

Date

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

Pre Breakfast:

2 Hours after Breakfast:

Pre Lunch:

2 Hours after Lunch:

Pre Evening Meal:

2 Hours after Evening Meal:

Before Bed:

Day 2

Date

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

Pre Breakfast:

2 Hours after Breakfast:

Pre Lunch:

2 Hours after Lunch:

Pre Evening Meal:

2 Hours after Evening Meal

Before Bed:

Day 3

Date

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

Pre Breakfast:

2 Hours after Breakfast:

Pre Lunch:

2 Hours after Lunch:

Pre Evening Meal:

2 Hours after Evening Meal

Before Bed:

Day 4

Date

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

Pre Breakfast:

2 Hours after Breakfast:

Pre Lunch:

2 Hours after Lunch:

Pre Evening Meal:

2 Hours after Evening Meal

Before Bed:

Day 5

Date

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

Pre Breakfast:

2 Hours after Breakfast:

Pre Lunch:

2 Hours after Lunch:

Pre Evening Meal:

2 Hours after Evening Meal

Before Bed:

Day 6

Date

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

Pre Breakfast:

2 Hours after Breakfast:

Pre Lunch:

2 Hours after Lunch:

Pre Evening Meal:

2 Hours after Evening Meal

Before Bed:

Day 7

Date

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

Pre Breakfast:

2 Hours after Breakfast:

Pre Lunch:

2 Hours after Lunch:

Pre Evening Meal:

2 Hours after Evening Meal

Before Bed: