Diabetes Questionnaire

Diabetes Questionnaire are a set of questions handed out to patients for diagnosing diabetes. These questionnaires are a testimony of the health condition by the patient themselves which help the doctors and healthcare professionals, to check the  risk factor. Diabetic patients need to be aware about their health conditions so that should answer the questions properly.

Sample Diabetes Questionnaire

Name:                               ______________________________________________________

Address:            ______________________________________________________

Phone No:          ______________________________________________________

Gender:             ________________              Age:         __________________

Height (cms):             ________________             Weight (lbs):        __________________

1. Please enter your waist size in inches which is measured around your navel: _______________________________________________________________
2. What is the total amount of time you spend on physical activity daily? Mention all exercises that you do. _______________________________________________________________
3. What is your daily intake of fruits and vegetables? _______________________________________________________________
4. Do you suffer from depression, stress or sleeplessness? _______________________________________________________________
5. Do you suffer from high blood pressure? If yes, have you taken medication on a regular basis? List down the medicines used. _________________________________________________________________.

_________________________________________________________________.

1. Does anyone from your family suffer from type 1 or type 2 diabetes? If so then mention your relationship with them.

_________________________________________________________________

1. Do you feel tired and restless during work or while walking, climbing up stairs? _________________________________________________________________
2. Do you monitor your blood glucose and cholesterol regularly? What was your last reading? _________________________________________________________________
3. Do you suffer from any disease of heart, lungs or any other chronic condition? ________________________________________________________________
4. Do you get any rashes or allergies on your skin? __________________________
5. Do you frequently get an urge to urinate (Y/N)? : _____________________
6. Do you feel thirsty quite often? How many glasses of water do you drink daily?

_______________________________________________________________.

1. Do you feel hungry or get cravings more than usual? What do you snack on when feeling hungry?

_______________________________________________________________.