What is your Full Name?
What is your registered Phone Number?
Does anyone else in your family has diabetes? If yes, then what is your relation with them?
Do you have addiction of any of the following? SmokingAlcoholChaaliyaPaan/GutkaNone
Do you have any history of high blood pressure? (Greater than 130/80 mmHg) YesNoNever checked
Do you have any history of high cholesterol? (Greater than 200mg/dL) YesNoNever checked
Rate your stress level on the following scale 12345678910
Do you have any of the following symptoms? HungerThirstFrequent urinationDry skinBlurred visionTiredness/fatigueNumbness/tingling in hands/feetUnusual weight loss/gainFrequent infectionsConstipation/DiarrheaExcessive sweatingDizzinessSlow wound healingMuscle wastingKidney infectionsDiabetic footDepressionOther
Any other complications:
Do you have chronic kidney disease? YesNo
Last eye exam (Please write null if you haven't done any)
Last dental exam (Please write null if you haven't done any)
Do you: Eat rapidlySkip mealsHave snacks between mealsHave unplanned mealsEat outside food/at restaurant frequentlyUse processed foodsOther
Select your activity level from the following: Sedentary (Little or no exercise)Lightly active (Exercise/sports 1-3 days/week)Moderately active (Exercise/sports 3-5 days/week)Very active (Exercise/sports 6-7 days/week)Other