Diabetes Screening

• Demographic Details
  Full Name *

  Enter First name

  Mr. Ms./Mrs. Master Baby

  Gender *

  Please Select Gender

  M

  F

  Age *

  Please Select Date of Birth

  Age must be greater than 0 and less than 125 Years

  Months must be less than 12

  Days must be less than 31

  -

  -

  Days

  Mnth

  Yrs

  Cancel

  Continue
• Diabetes Screening
  Do you have immediate family history of any of the adjacent diseases? *  

  Please Enter Do you have immediate family history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Others None

  Do you have history of any of the adjacent diseases? *

  Please Enter Do you have history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease/Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Nutritional deficiencies (Vitamin B12/D/Calcium/Iron) Others None

  Are you on any Diabetes Medication? *

  Please Enter Are you on any Diabetes Medication?

  Yes No

  How long has it been since you are on Diabetes medicines? *

  Please Enter How long has it been since you are on Diabetes medicines?

  Are you taking them regularly? *

  Please Enter Are you taking them regularly?

  Yes No Occasionally

  Do you always feel thirsty? *

  Please Enter Do you always feel thirsty?

  Yes No

  Any numbness or tingling sensation in your hand/feet? *

  Please Enter Any numbness or tingling sensation in your hand/feet?

  Yes No

  How many times do you wake up at night for Urination? *

  Please Enter How many times do you wake up at night for Urination?

  Do you feel dizzy sometimes? *

  Please Enter Do you feel dizzy sometimes?

  Yes No

  Do you consume Tobacco in any form(Smoking/Chewing)? *

  Please Enter Do you consume Tobacco in any form(Smoking/Chewing)?

  Never Reformed Current

  Height  

  Cms

  Feet

  Inches

  Weight *

  Please Enter Weight

  Waist *

  Please Enter Waist

  Hip *

  Please Enter Hip

  BMI

  Please Enter BMI

  WHR

  Please Enter WHR

  BloodSugar Category

  Please Enter BloodSugar Category

  Random Fasting PostPrandial

  Blood Sugar

  Please Enter Blood Sugar

  Blood Sugar

  Please Enter Blood Sugar

  Cancel Back

  Submit