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Patient Information Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

Secured
1

What is the patient's name?

Please provide the patient's name.
2

What is the patient's path number?

Please provide the patient's path number.
3

How old is the patient?

Please provide the age of the patient.
4

What is the patient's sex?

Please select the patient's sex.
5

What is the patient's weight?

Please provide the weight of the patient.
6

What is the patient's height?

Please provide the height of the patient.
7

What is the patient's BMI (Body Mass Index)?

Please provide the BMI of the patient.
8

What is the patient's educational status?

Please select the patient's educational status.
9

What is the patient's marital status?

Please select the patient's marital status.
10

Is the patient diabetic?

Please select the diabetic status of the patient.
11

If diabetic, how long has the patient had diabetes?

Please provide the duration of diabetes if patient is diabetic.
12

If diabetic, what type of diabetes does the patient have?

Please select the type of diabetes if patient is diabetic.