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Diabetes  Pre-assessment Questionnaire

Thank you for taking the time to complete this questionnaire. Managing your diabetes is a top priority for both your health and well-being, and your feedback will help us provide the best care possible.

We kindly ask you to answer the following questions regarding your diabetes management, care plans, and education needs. Your responses will be carefully reviewed by a clinician, and if necessary, we will invite you for a follow-up appointment.

Our goal is to work closely with you to support your health and well-being.

Dr Emiliani
Earls Court Surgery

Your full name?


Your weight in kilogram?

Did you have a recent Blood Pressure reading?

Did you have a recent Blood Pressure reading?
A
B

Are you experiencing any medication side-effects?

Are you experiencing any medication side-effects?
A
B