Risk Assessment: Type 2 Diabetes

For more information about reducing your risk of Type 2 Diabetes, please read our leaflet.

If you have been advised by the surgery to submit a Type 2 Diabetes risk assessment please use this form.

We can refer patients, who have been told that they are at risk of developing type 2 diabetes, to the Healthier You programme.

By joining this programme, patients will receive a personalised support plan including advice on healthy eating and lifestyle, help to lose weight and physical exercise programmes.

Risk of Type 2 Diabetes Referral form

Risk of Type 2 Diabetes Referral form

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.
Have you been advised by the practice that you are at risk of developing type 2 diabetes? *
If you happy to share your record with the provider of this service please tick Yes you agree. We are unable to process the referral without your consent. *
Would you like us to refer you to the Healthier you programme or would you like more information?