At risk of diabetes review

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Height and weight

Height in metres

For example, 1.75

Weight in kilograms

For example, 60.6

BMI

Blood pressure

Date of reading

For example, 31/03/1980

Systolic

mmHg

Diastolic

mmHg

Pulse

/min

Smoking

Are you a current smoker?

Yes

No

Alcohol consumption

How many units of alcohol do you drink on a weekly basis?

Confirmation

I confirm that this problem is not urgent or an emergency. I understand that the practice will not process this request when it is closed and that it will be reviewed within two working days.

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Height and weight

Blood pressure

Smoking

Alcohol consumption