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Diabetes Health Assessment Questionnaire

Your Name:
Q2. Is there family history of diabetes?:
Yes No
Q3: Is there anyone else who has Diabetes?
No Yes, a friend, parent,sister or brother also has Diabetes
Q4. Which type of Diabetes do you belong to?
Not sure Type 1 Diabetes Type 2 Diabetes Borderline Diabetes Pregnancy Diabetes Diabetic Nephropathy
Q5.What is your fasting blood glucose?:
Q6:What is your C-peptide test result?
0.51-2.72 ng/ml or 0.17-0.90 nmol/L Less than 0.51mg/ml or 0.71nmol/l Higher than 2.72 ng/ml or 0.90 nmol/l Not sure
Q7. What is your last hba1c test result?:
Q8. What method do you apply to control blood glucose?
Regular exercise Insulin injection Oral medicines Dietary therapy Visit doctors regularly
Q9. Do you think you have managed diabetes well?
Q10. If your Diabetes has been poorly controlled, what are the reasons?
Not enough rest
In the habit of smoking or drinking alcohol
Did not take hypoglycemic medicines or insulin timely
Not doing exercise regularly
Poor dietary controlling
Q11. What symptoms of Diabetes do you have?
Thirst Weight loss Over obesity Frequent urination Over fatigue Walking Difficulty Nerve pains Numbness and tingling sensations Blurred vision or Vision Loss Diarrhea Constipation Sexual Dysfunction or Impotence Skin blisters Skin itching Dizziness Protein in urine foamy or bubby urine Swelling Difficult wound healing Cardiovascular system obstructions
Symptoms of hypoglycemia:
Chest pains chest suppression palpation or abnormal sweating
Q12.If you need any of the following information, you may leave a message to us.
1. Treatment Option and latest medical progression for Diabetes
2. Analysis of your specific illness condition
3. Dietary or nursing plan of Diabetes
4. Management for Diabetic complications

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