Diabetes Review

If you have been advised by the surgery to submit a 6 month review please use this form.

If you have any concerns please make an appointment with our Nurse.

Diabetes and Driving

You can be fined up to £1,000 if you don’t tell DVLA about a medical condition that affects your driving. You may be prosecuted if you’re involved in an accident as a result.

You must tell DVLA if your diabetes is treated with insulin.

Please view more information including current DVLA guidelines regarding driving with diabetes.

Diabetes Review

If you are human, leave this field blank.

About You

Full Name *

Date of Birth *

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

Phone Number

Email Address *

Can we contact you by email?

Yes

Can we contact you by text message?

Yes

Your Diabetes Review

HbA1c

Total Cholesterol

Height

Weight

Do you smoke?

Yes

Blood Pressure

Heart Rate

Systolic "Higher"

Diastolic "Lower"

Date of your last Retinal Screening

Right eye

Left eye

Other Issues

Please let us know any issues you have with your diabetes or health in general:

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

I confirm that the information provided is accurate to the best of my knowledge.

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Diabetes and Driving

Diabetes Review

About You

Your Diabetes Review

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