Pre-Diabetic Questionnaire

To help our Health Care Assistant in your appointment, we ask that you complete the following questionnaire. Thank you.

Pre-Diabetic Questionnaire

Pre-Diabetic Questionnaire

Health Questions

Do you currently smoke? *
If you are a current smoker, we strongly suggest you consider stopping. You may wish to go to our wellbeing centre, where there is a stop smoking form.
Eg. For example 6 small glasses of red wine a week, 2 pints of beer.
Please count any exercise activities that raise your heart rate.

Your Blood Pressure

If possible, please list a week's worth of readings, one per day:

Day 1

Your Reading:
/

Day 2

Your Reading:
/

Day 3

Your Reading:
/

Day 4

Your Reading:
/

Day 5

Your Reading:
/

Day 6

Your Reading:
/

Day 7

Your Reading:
/

Additional Information:

E.g. Medication changes, feeling unwell etc.
*