Name : *

Age : *

Gender *
MaleFemale

Address :


City : *

Zip Code : *

Country : *

Phone Number : *

E-mail : *

Since when are you suffering from Diabetes Mellitus ?

Are you suffering from Type-1 or Type-2 Diabetes Mellitus ?
Type-1Type-2Don’t Know

What medicines are you using to lower blood glucose level ?

Are you feeling loss of energy ?
YesNo

Do you feel thirsty after drinking water / liquids ?
YesNo

How many times do you have to go to urinate ?

So your siblings or parents suffer from Diabetes Mellitus ?
YesNo

Do you have other problems such as high Blood pressure , high cholesterol, heart disease, diabetic neuropathy, retinopathy ?
YesNo

Is your eye vision clear ?
YesNo

What is your fasting blood sugar level ?

What is your blood sugar level after meals ?

What type of food do you use in food ?
VegetarianNon Vegetarian

Do you exercise regularly ?
YesNo

Do you use any pain killer medicines ?
YesNo

Do you have any tests reports done ? If yes then kindly upload reports. (10 MB Maximum File Size.... Preferably send zip files. If you have more files then email separately to drharishverma@gmail.com)

Do you have any current medication going on ?

If you have any other information to share then please describe below :