Patient History form for : Madhumeh (Diabetes Mellitus)

Name : *

Age : *

Gender *
 Male Female

Address :

City : *

Zip Code : *

Country : *

Phone Number : *

E-mail : *

Since when are you suffering from Diabetes Mellitus ?

Are you suffering from Type-1 or Type-2 Diabetes Mellitus ?
 Type-1 Type-2 Don’t Know

What medicines are you using to lower blood glucose level ?

Are you feeling loss of energy ?
 Yes No

Do you feel thirsty after drinking water / liquids ?
 Yes No

How many times do you have to go to urinate ?

How many times do you have to go to urinate ?
 Yes No

So your siblings or parents suffer from Diabetes Mellitus ?
 Yes No

Do you have other problems such as high Blood pressure , high cholesterol, heart disease, diabetic neuropathy, retinopathy ?
 Yes No

Is your eye vision clear ?
 Yes No

What is your fasting blood sugar level ?

What is your blood sugar level after meals ?

What type of food do you use in food ?
 Vegetarian Non Vegetarian

Do you exercise regularly ?
 Yes No

Do you use any pain killer medicines ?
 Yes No

Do you have any tests reports done ? If yes then kindly upload reports. (10 MB Maximum File Size.... Preferably send zip files. If you have more files then email separately to

Do you have any current medication going on ?

If you have any other information to share then please describe below :

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