Diabetes Assessment Form
Diabetes Assessment Form
Please fill out this form with accurate and complete details.
Date
Name
Gender
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Male
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Female
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Date of Birth
Height (in inches)
Weight (in pounds)
How often do you consume sugary drinks or desserts?
How often do you engage in physical activity?
Do you currently smoke?
Have you been diagnosed with high blood pressure or high cholesterol?
Do you have a family history of diabetes?
Additional Information
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