Diafree - form

Details of your health
Name
Address
Country
Tel
Fax
E-Mail
Age
Sex	male female
Height	cms
Weight	kg
Food habits
Mode of work
Regular physical activities
How is your eye sight?
How is your sexual ability?
How is your appetite?
Do you have constipation regularly?	Yes No
How is your Periods (For Female)	Regular Irregular
Any other physical problems you have?	Yes No
Any mental stress you have?	Yes No
Are you Married?	Married Single Divorcee
How many children you have	Male Female
Do you have hair loss often?	Yes No
Do you have joint pain?	Yes No
Do you get giddiness?	Yes No
Do you have gastric problems?	Yes No
Do you have peptic ulcer?	Yes No
How many year you are suffering from Diabetes?
Do you have High BP?	Yes No
Did you have the habit of smoking?	Yes No
Did you consume liquor?	Yes No
Did you like much sweets?	Yes No
Did your fore fathers or parents have diabetes?	Yes No
Your latest blood and urine glucose reports,	Blood Fasting Blood PP / Urine Fasting Urine PP
Your HbAlc report:
What are the medicines you consume at present?
Any other health details you want to tell us to get remedy
Kindly send us all your health problems