Name How long has patient had Diabetes for? What is the patient’s ethnicity? Is there a family history of diabetes? Does the patient work? What hours Who manages their Diabetes ? Does the patient see a regular doctor / nurse in the practice? If so then who? What different medications has the patient been on? Is the patient on maximum tolerated therapy ? Is compliance good? Does the patient understand what they are taking ? How many different medications does the patient take in a day? Does the patient ever have difficulties remembering what they have to take? Is the patient cared for? Do the carers know what diabetes is about? What is the Body Mass Index ? Does the patient ever miss appointments ? What complications does the patient have? Does the patient have other comorbidities? Is the patient depressed? How has it been treated? Is the patient on the internet? Does the patient wish to sign up for Records Access? Has the patient tried the UKPDS Risk Engine? Does the patient smoke? What successes has the patient had to change their lifestyle ever? Families help families. Is there somebody who can help them with their diabetes ? Does the patient monitor any aspect of their health ? Does the patient have a smartphone? What goals does the patient have? Date Years Latest HbA1c Better / Same / Worse Parents / Brothers / Sisters / Children / Uncles / Aunties Yes – full time / part-time / shift work No Practice / Diabetes Specialist Nurses / Hospital Doctor Nurse Metformin / Sulphonylureas / Glitazones / Byetta / Insulin / Other: Yes No Yes No Yes No Yes No >50 <50 Never / Occasionally / Sometimes / Often / Always Why? Retinopathy / Autonomic Neuropathy / Peripheral Neuropathy / Peripheral Vascular Disease / IHD / Nephropathy Yes No Yes No Yes No Smoker / Ex-smoker / Non-smoker Blood Pressure / Weight / Blood sugar