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Patient Health Survey
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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Diagnosing of diabetes mellitus
1
Patient Name
Please enter the name of the patient.
2
Path Number
Please enter the path number of the patient.
3
Age
Please select the age range of the patient.
0-20
21-40
41-60
61-80
Above 80
4
Sex
Please select the gender of the patient.
Male
Female
Other
5
Weight
Please enter the weight of the patient in kilograms.
6
Height
Please enter the height of the patient in centimeters.
7
BMI
Please calculate and enter the BMI of the patient.
8
Educational Status
Please select the educational status of the patient.
Primary school
High school
University
Postgraduate
9
Marital Status
Please select the marital status of the patient.
Single
Married
Divorced
Widowed
10
Diabetes Status
Please select the diabetes status of the patient.
Diabetic
Non-diabetic
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Diagnosing of diabetes mellitus
11
Duration of diabetes
Select one or more answers
less than 1 year
1 - 5 years
6 - 10 years
more than 10 years
12
Type of diabetes
Select one or more answers
type 1
type 2
other type
If other type, specify................................................................
Submit
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