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 drharishverma@gmail.com)

Do you have any current medication going on ?

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


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