Name

Sex

Date of Birth

Day   Month   Year  

Phone Number

Email Address

 Optional

Address 1

Address 2

Town

County

Post Code

Now we need to find out what sort of treatment you are on. Please choose from one of the following:

My diabetes is controlled by:-

DIET ONLY

TABLETS ONLY

TABLETS and INSULIN

INSULIN ONLY but I have had tablets in the past

INSULIN ONLY and I have NEVER had TABLETS

Please say when your condition was first diagnosed.

Have you had any formal education about your condition over and above the sort of basic information and advice given at your GP practice?