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

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  Days

  Mnth

  Yrs

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• 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

  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

  Blood Sugar

  Please Enter Blood Sugar

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