Pre-Diabetic Questionnaire

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

If you are human, leave this field blank.

Health Questions

Do you currently smoke? *

Yes

How many cigarettes do you smoke a day?

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.

If you smoke a pipe or tobacco, please confirm the type and amount per day:

If you drink alcohol please can you write your normal drinks, and how frequently you have them in a week:

Eg. For example 6 small glasses of red wine a week, 2 pints of beer.

Current Weight:

How many times a week do you exercise?

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

Date:

Time:

Your Reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 2

Date:

Time:

Your Reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 3

Date:

Time:

Your Reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 4

Date:

Time:

Your Reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 5

Date:

Time:

Your Reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 6

Date:

Time:

Your Reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 7

Date:

Time:

Your Reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Additional Information:

Any further comments or notes:
E.g. Medication changes, feeling unwell etc.

*

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

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