Patient Name *
Sex *MaleFemale
Height *
Weight *
Age *
E-Mail *
Phone *
How many years are you with diabetes? *
Please indicate who else in your family has diabetes. (You may choose multiple)
Me
Father
Mother
Brother
Sister
Child
Other Relatives
Please indicate how many years your family has diabetes. *
Medicines used for Diabetes in 1st 5 years
What medicines are you having presently?
Dosage
Are you on insulin?YESNO
HypertensionYESNO
Kidney ProblemsYESNO
Eye ProblemsYESNO
Leg tingling / non-healing leg ulcerYESNO
Cardiac ProblemYESNO
Thyroid ProblemYESNO
High Uric AcidYESNO
High Cholesterol or TriglycerideYESNO
TuberculosisYESNO
AsthmaYESNO
ParalysisYESNO
Liver problems / JaundiceYESNO
Problem with ErectionYESNO
Pancreas ProblemYESNO
SmokingYESNO
If smoking... Since? Quantity?
AlcoholYESNO
If drinking... Since? Quantity?
Any previous abdominal operations?YESNO
Diet ControlYESNO
Exercise?YESNO
Why do you want to undergo operation for diabetes?
What do you expect after surgery?
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