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Patient History

Please fill this form, let the doctors understand your case, get suggestions from Doctors.
I have an appointment ID:

Patient Name :
Age :
Weight : Kgs.
Height : Cms.
Address 1 :
Address 2 :
City :
Country :
Pin :
E-mail :
Phone Number :
Mobile Number :
Diabetes detected in :
Me     Mother  
Father     Brothers  
Sisters     Children  

Medicines used for Diabetes in 1st 5 years :

What medicines are you having presently :
Dosage :


Are you on insulin :
Yes   No

Associated Medical Problems :
Hypertension (High Blood Pressure) :
Yes   No
Kidney problems :
Yes   No
Eye problems :
Yes   No
Leg tingling/ non-healing leg ulcer :
Yes   No
Cardiac problem :
Yes   No
Thyroid problem :
Yes   No
High Uric Acid :
Yes   No
High Cholesterol or Triglyceride :
Yes   No
TB :
Yes   No
Asthma :
Yes   No
Paralysis :
Yes   No
Liver problems / Jaundice :
Yes   No
Problem with Erection :
Yes   No
Pancreas problem :
Yes   No

Habits :
Smoking   since   quantity
Alcohol   since   quantity
Tobacco   since   quantity

Any previous abdominal operations ?
Yes   No

Diet Control :
Yes   No

Exercise :
Yes   No

Why do you want  to undergo operation for diabetes ? :

What do you expect after surgery ? :

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