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Diabetes Treatment Form
Fill all the fields, if you want complete treatment
   
*Name
*E-mail
*Address
*City
*State
*Zip Code
*Country
 
Sex / Age  / 
Weight / Height /  
Occupation
   
Marital status
If married how many
Children
Singal Married
 
What about your memory Sharp    Weak  
Do you take your food timly Yes        No
Do you feel weakness in your body Yes        No
Do you feel Irritation in both legs & hands Yes        No
Do you feel pain in joints & backbone Yes        No
Are you suffering from any sex related disease Yes        No

Do you feel to much hungry Yes        No
Is your stool sticky (Greasy) and find some Problem Yes        No
How many times you pass urine during night
For how long you have been suffering from diabetes
Do you take insulin (If yes)
In what Quantity
Yes        No
What kind of Medicine taken earlier Allopathic
Homeopathic
Ayurvedic     
Unani
Percentage of sugar in blood & urine
How much water do you drink every day (in Ltr.)
Are you suffering from blood pressure
If yes,
Yes        No
HBP       LBP
Do you have heart problem Yes        No
Are your doing exercise daily Yes        No
What about your eye sight Weak     Strong
Is your diabetes hereditary or accidental
Are you suffering any other disease
If yes, specify in detail
Yes        No
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