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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