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Medical Evaluation Form – Diabetes

Medical Evaluation Form - Diabetes

Thank you for your interest in our service.


In order for our medical team to evaluate whether or not you are eligible for treatment and recommend a relevant medical program and treatment for you, please fill in the form below to the best of your ability or with the help of your physician.

  • Name *

  • Date of Birth *

  • Country

  • Email *

  • Phone

  • Height

  • Unit

  • Weight

  • Unit

  • History and Diagnosis

  • What is your Primary diagnosis? *

  • When were you first diagnosed?

    MM

    DD

    YYYY

    If you don't remember the specific date, just fill in the year of diagnoses with or without month.

  • Please describe the progression of your condition from early symptoms until now.

  • What is your daily insulin dose? What other medications you are taking to control the blood glucose (dose and response)?

  • Does anyone in your family have medical history relevant to your condition? Type 1 or 2?

  • Symptoms

  • Please list all your current symptoms: (appetite/performance of daily activities/fatigue/vision/breathing/ chest pain/ headache/ dizziness/ etc.)

  • Medications

  • Please list the medications you are currently taking other than medications you listed above:

  • Except for the insulin and medications, have you taken other medical therapies? If yes, please clarify the treatment, date and results.

  • *Fasting blood glucose, *Random Plasma Glucose, *HbA1c, *C-peptide test, *CTT, Oral glucose tolerance test, Lipid Panel, *Urine Analysis, EKG, and other tests you think it may be relevant. The tests with stars are most need.

  • Please list the diagnostic exams you have had along with date, results and if images are available on request.

  • Any medical records that you can send us will be helpful for your medical evaluation.

    If possible, please attach to the form below any or all of the following:

    MRI / CT images (on CD, Film, or via email)

    Medical records or recent neurological evaluation from your neurologist

    Video: a short video (3-5 minutes) showing the patient performing simple daily activities. You may use a simple home camera to prepare this video and send us via email or on a CD.

  • File

  • File

  • File

  • File

  • File

  • Hypertension

  • Heart disease

  • Pneumonia

  • Diabetes

  • Hyperlipidemia

  • CVA/ Stroke

  • Lung disease

  • Liver disease

  • Kidney disease

  • Fracture or break

  • Cutaneous basal cell carcinoma or in situ carcinoma

  • Cancer or tumor

  • Inflammation or infection

  • Others

  • Other information

  • Is there a caregiver who can provide you with care and assistance during your stay at the hospital if necessary?

  • Do you smoke?

  • Are you currently using or ever used drugs or alcohol?

  • Do you have sleep apnea, chronic obstructive pulmonary disease or other condition that doesn't allow for general anesthesia?