Patient Name *
How many years are you with diabetes? *
Please indicate who else in your family has diabetes. (You may choose multiple)
Please indicate how many years your family has diabetes. *
Medicines used for Diabetes in 1st 5 years
What medicines are you having presently?
Are you on insulin?YESNO
Leg tingling / non-healing leg ulcerYESNO
High Uric AcidYESNO
High Cholesterol or TriglycerideYESNO
Liver problems / JaundiceYESNO
Problem with ErectionYESNO
If smoking... Since? Quantity?
If drinking... Since? Quantity?
Any previous abdominal operations?YESNO
Why do you want to undergo operation for diabetes?
What do you expect after surgery?
Esentepe Mah. Büyükdere Cad. Oya Sk. No:2 34394 Şişli İstanbul Türkiye (+90) 212 953 2020 firstname.lastname@example.org
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