Diabetes Review Programme Your Details Full Name * Mobile Number * Date of Birth * Please use this date format: DD/MM/YYYY. Patients with diabetes tell us that that they may experience the following concerns. Please consider the degree to which each of these 2 items may have distressed or bothered you during the past month. Feeling overwhelmed by the demands of living with diabetes * Not a problem A slight problem Quite a problem A serious problem A very serious problem Feeling that I am often failing in my diabetes routine * Not a problem A slight problem Quite a problem A serious problem A very serious problem During the past month, have you: Often been bothered by little interest or pleasure in doing things? * Yes No Often been bothered by feeling down, depressed or hopeless? * Yes No Over the past two weeks, how often have you been bothered by the following problems? Feeling nervous, anxious or on edge * Not at all Several day More than half the time Nearly every day Not being able to stop or control worrying * Not at all Several day More than half the time Nearly every day Is there anything you feel the Surgery could do to assist you further in the treatment of your diabetes? * Earlier we mentioned the Hertfordshire NHS Wellbeing service; if we feel it is appropriate may we share your response with an NHS Wellbeing Clinician for them to contact you to arrange a consultation to discuss how they might be able to help you further? * Yes No
altings Surgery
8-14 Victoria Street, St Albans, AL1 3JB