Diabetes review Diabetes Review First, a few details about you Name * First Last * Last Date of Birth * Preferred Contact details if we need any clarification (Email or telephone number) * Let’s start with a few details about your life style Current weight Current height How much exercise have you done over the last week No activity No more than one or two times in the week About three or four times a week Almost daily Daily How often do you drink alcohol? Never Monthly or less Two or four times a month Two or three times a week Four or more times a week How many units of alcohol are consumed when you drink? 1-2 3-4 5-6 More than 6 Regarding your smoking… Never smoked Gave up smoking Smokes occasionally Smokes daily Only smoke e-cigarettes Smoking is particularly a concern with diabetes. You should stop. Would you consider it? Yes, I would. Not at present. If you have checked your blood pressure yourself, what has been the latest value If you have checked your blood sugar yourself, what has been the latest range of values If you can, ask somebody to help you to test for sensitivity in your feet If you would like information on how to the touch the toes test please visit www.diabetes.org.uk/guide-to-diabetes/complications/feet/touch-the-toes Able to do test? While you lay down with your bare feet and closed eyes. Get your helper to touch lightly and briefly (1-2 seconds) the tips of the first, third and fifth toes of both feet with the index finger. Write below how many of the touches you felt accurately on each foot Regarding your feet, have you had recently burning or tingling foot pain swollen feet or ankles change in the appearance of one or more nails? or any cuts or scratches Have you had your eyes checked over the last year? Yes No Have you been in hospital since the last time we saw you Yes No Submit If you are human, leave this field blank.