Your Name

Sex
 Male Female

Age


Address


Mobile

email

Qualification

Diabetes since how many years?
 < 5Years > 5Years > 10Years


 Blood Pressure High Cholesterol Heart Attack Kidney Disease Eye Disease


 Neuropathy Dental Carries Do You Smoke Foot Injury that not healing


Do you have any Sexual Problem?
 Yes No


Do you take medicines, prescribed by Doctor?
 Regularly Irregularly


Which of the following medicines you take for diabetes?
 Oral Insulin Both


Have you been explained about your diet in brief by your Doctor/Dietician?
 Yes No


Have you been provided education about Diabetes by your Doctor/Dietician?
 Yes No


How often do you exercise/walk?
 Daily < Less than 3 times a week > More than 3 times a week


Do you have Glucometer to measure your blood glucose?
 Yes No


Do you know about self monitoring of blood glucose?
 Yes No


How often do you check your blood glucose?
 Weekly Monthly 3 Monthly 6 Monthly Yearly


Do you know about HbA1c?
 Yes No


How often do you check HbA1c?
 Weekly Monthly 3 Monthly 6 Monthly Yearly


How often do you check lipid profile?
 Weekly Monthly 3 Monthly 6 Monthly Yearly


How often do you check your urine for microalbumin in?
 Weekly Monthly 3 Monthly 6 Monthly Yearly


How often do you visit your doctor?
 Weekly Monthly 3 Monthly 6 Monthly Yearly


How often do you have dilated eye examination?
 Weekly Monthly 3 Monthly 6 Monthly Yearly

How often do you check your foot?
 Weekly Monthly 3 Monthly 6 Monthly Yearly

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