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FOR PREDIABETES

Use this evaluation form to record your measures from today’s Special Event

Share this completed form with your health care provider and discuss any measures that may be warning signs associated with diabetes—and what you can do about them. Fill out the form. This information is not intended as a substitute for professional medical care. Only your health care provider can diagnose and treat a medical problem.




Name



Email


Contact No


Whatsapp No



Age


Gender


Country


Body Measurements


Height:


Weight:


Waist:


BMI:


Physical Activity


How much exercise do you get?


Very little

Some

Quite a bit

How often?


Not very often

1-3 times a week

4-7 times a week

Diet/Nutrition


I generally eat low-fat meals, high in fruits, vegetables, and whole-grain foods.


True

False

Tobacco


Smoker

Nonsmoker

Stress


My current stress level is Low

High

Very high

Family History


Is there a history of heart disease in your family?


Yes

No

Do you have a brother or sister with diabetes?


Yes

No

Do (or did) either of your parents have diabetes?


Yes

No

Blood Sugar Levels


Have you had a fasting blood sugar test in the past 12 months?


Yes

No

Don’t know

Has your physician ever told you that your blood sugar was a little high and that

you should watch your diet and increase your daily exercise?


Yes

No

Don’t know

Symptoms


In the past 30 days, have you experienced any of the following?

Excessive thirst


Yes

No

Frequent urination


Yes

No

Excessive hunger


Yes

No

Persons Diagnosed With Diabetes


I am currently taking medication for my diabetes.


Yes

No

My A1C level is



Don’t know

My current fasting blood sugar is



Don’t know

I would like additional information to help me better manage my diabetes.


Yes

No

IF MEASURED AT YOUR SPECIAL EVENT:


Cholesterol and Triglycerides


Total:

HDL:

Blood Pressure


Systolic

Diastolic

Blood Sugar


Blood Sugar