Home
About Us
About
Our Team
About Madhumeha Trust
Publication and Activity
Diabetes Basics
Origin of Diabetes
History of Diabetes
What is Diabetes
Types of Diabetes
Causes of Diabetes
How We Care
How We Care
Diabetes Risk Profiler
Insulinoma
Hypo-Glycaemia
Ketoacidosis
Diabetic Complications
Blogs
FAQ
Appointments
Online Consultation Form
Appointments
Products
Gallery
Contact Us
Dedicated 20 Minutes for Patient
Details of patient
Personal History
--Gender---
Male
Female
Gynane./Obst. History -Menstrual History- If Female
--Weight---
Our Weight
Under Weight
--Delivery---
Normal
Surgical
--Habit of smoking--
Yes
No
--Habit of chewing tobaco--
Yes
No
--Habit of alcohol--
Yes
No
Family History
Anybody in the family had Diabetes
--Anybody in the family had Diabetes---
Yes
No
History of Present Illness
Previous Treatment
History of Present Illness
Polydipsia (Excessive thirst)
--Please Select---
Yes
No
Polyuria (Excessive urination)
--Please Select---
Yes
No
No. of Urine /Day
--Please Select---
Yes
No
No. of Urine /Night
--Please Select---
Yes
No
Appetite (Hunger)
Normal
Less
Increased
Bowels
Regular
Irreguar
Constipation
--Please Select---
Yes
No
Weight
Loss
Gain
Constant
Muscular Pain
--Please Select---
Yes
No
Maliase/Fatigue (Tiredness)
--Please Select---
Yes
No
Palpitation (Increased heart beat)
--Please Select---
Yes
No
Chest Pain/Discomfort
--Please Select---
Yes
No
Dyspnea (Breathing discomfort) with Mild Exertion
--Please Select---
Yes
No
Oedema (Swelling)
--Please Select---
Yes
No
Irritability
--Please Select---
Yes
No
Visual Disturbance
--Please Select---
Yes
No
Giddiness (Dizziness)
--Please Select---
Yes
No
Sleep
Normal
Distrub
Excessive
Joints Pain
--Please Select---
Yes
No
Cramp (Night
--Please Select---
Yes
No
Itching
--Please Select---
Yes
No
Sweating
Normal
Profuse
Less
Submit
Reset