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The Chipping Surgery NHS GP Surgery in Gloucestershire

Weight management service

Weight Management Service

Required fields are labelled

You must be aged 13 or over to complete this form yourself

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Information:

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Who are you completing this form for? Required

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

What is your ethnic group? Required

White: British

White: Irish

White: Irish Traveller

White: Traveller

White: Gypsy/Romany

White: Polish

White: Any other White background

Mixed: White and Black Caribbean

Mixed: White and Black African

Mixed: White and Asian

Mixed: Any other Mixed background

Asian or Asian British: Indian

Asian or Asian British: Pakistani

Asian or Asian British: Bangladeshi

Asian or Asian British: Any other Asian background

Black or Black British: Caribbean

Black or Black British: African

Black or Black British: Somali

Black or Black British: Nigerian

Black or Black British: Any other Black background

Other ethnic group: Chinese

Other ethnic group: Filipino

Other ethnic group: Any other ethnic group

Prefer not to say

Specify your ethnic group: Required

Have you had a diagnosis of any of these conditions? Required

High blood pressure (hypertension)

Non-diabetic hyperglycaemia (pre-diabetes)

Type 1 diabetes

Type 2 diabetes

No, I have none of these

Have you had a diagnosis of type 2 diabetes within the last 6 years? Required

Yes

No

Have you had a blood sugar (HbA1c) measurement taken within the last 12 months? Required

Yes

No

Do you take diabetes medication? Required

Yes

No

Was the blood sugar measurement between 43 to 87 mmol/mol? Required

Yes

No

I don’t know

Was the blood sugar measurement between 48 to 87 mmol/mol? Required

Yes

No

I don’t know

Did you have a diabetes review when it was last offered (including eye screening)? Required

Yes

No

Will you continue to have annual reviews even if you are in remission? Required

Yes

No

Height (Metres): Required

For example, 1.75

Weight (Kilograms): Required

For example, 60.6

BMI:

You can find more information and advice for adults and children about healthy weight on the NHS website.

Do you consent to a referral to an NHS weight management service? Required

Yes

No

If you are human, leave this field blank.

Symn Lane
Wotton-under-Edge
Gloucestershire
GL12 7BD

Get directions

01453 842214

Register with the surgery

Feedback and complaints

Wellbeing

Chipping Surgery

CQC overall rating

Good

10 November 2016

See the report

Accessibility statement

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