Name
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Whatsapp number
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Email
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Occupation
Height (m)
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Weight (kg)
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Age
Arm (inches)
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What is your waist circumference? Stand and place a tape measure around your middle, just above your hipbones
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What is your hip circumference? Use a tape measure to check the distance around the smallest part of your waist, just above your belly button
What tribe are you from?
What is your highest level of education?
Do you have financial concerns that may affect your Diabetes Care?
Who makes your meals?
When were you first diagnosed diabetic? What type of diabetes do you have?
When did you last test your blood sugar?
What is your most recent HbAIC result?
What is your most recent fasting blood sugar?
Have your blood sugar ever been above 200mg/dl?
Have your blood sugar ever been below 70mg/dl?
Do you keep a record of blood sugar in a book or diary?
Any other disease condition, please specify
Stress- Your level on a scale of 1 to 10: (10 = very high):
Do you have difficulty with hearing?
Are there times when you have difficulty seeing?
How often do you examine your feet (daily, weekly, rarely)?
Do you have any food intolerances or allergies? If yes, what?
Do you avoid any food? If Yes, list them
Are you on any medication, please specify
Do you use dietary supplements, if yes, please specify
Currently following any type of nutrition diet? If yes, what?
Has your doctor given you permission to exercise?
Has your doctor recommended any exercise regimen for you?
What are your limitations to exercise?
How often do you exercise? and how many minutes of exercise do you do?
What kind of exercises do you do? eg Homework/yardwork, Walking, Strength training, gym, etc
Do you have a problem with alcohol, like the tendency to overdrink
Are there any nutrition issues/topics you wish to discuss or have clarified? If yes, please state the topics.
Do you eat 2 or more servings of vegetable /day?
Do you eat 2 or more servings of Fruits /day
Do you skip meals?
Do you eat at restaurants and how frequently?
How often do you eat starchy foods such as breads, cereal, pasta, beans, crackers etc
How often do you take cookies, ice cream, other deserts
If you are human, leave this field blank.
SUBMIT