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
Hypertension YESNO
Kidney Problems YESNO
Eye Problems YESNO
Leg tingling / non-healing leg ulcer YESNO
Cardiac Problem YESNO
Thyroid Problem YESNO
High Uric Acid YESNO
High Cholesterol or Triglyceride YESNO
Tuberculosis YESNO
Asthma YESNO
Paralysis YESNO
Liver problems / Jaundice YESNO
Problem with Erection YESNO
Pancreas Problem YESNO
Smoking YESNO
If smoking... Since? Quantity?
Alcohol YESNO
If drinking... Since? Quantity?
Any previous abdominal operations? YESNO
Diet Control YESNO
Exercise? YESNO
Why do you want to undergo operation for diabetes?
What do you expect after surgery?
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