Type 2 Diabetes Review Form

The practice will contact you to arrange any blood tests and if a foot check is needed.

Once the team have the details from your form and any tests / checks they will contact you in a few weeks to discuss your condition and medication.

Information on Type 2 Diabetes on the NHS website

You will need to provide your blood pressure readings as part of this review. Home Blood Pressure Diary Downloads:

Or complete the online Blood Pressure Review Form.

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

Home Address

Postcode

Best telephone number to contact you

One of the clinicians will call you on the number provided in the next couple of weeks

Review Questions

HeightSpecify if in cm or ft / in

WeightSpecify if in kg or stones / lbs

Do you smoke?

How active are you?

Could your diet be healthier?

Do you drive?

Are you having problems with your feet?

Provide any comments for the clinician here

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Ongar Health Centre • Ongar War Memorial Medical, Fyfield Road, Ongar, Essex, CM5 0AL.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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