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Diabetes Patient Application Form

Collects the personal and clinical details needed to enroll a new patient in a diabetes management program.

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Full name

Nombre

Apellido

Date of birth

Gender

Male Female Other

Email address

Phone number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Date of diabetes diagnosis

Type of diabetes

Type 1 Type 2 Gestational Prediabetes

Current medication

Allergies

Previous diabetes-related hospitalizations or surgeries

Family history of diabetes

Yes No

Specify the relationship

Frequency of high blood sugar episodes

Never Rarely Sometimes Often Daily

Frequency of low blood sugar episodes

Never Rarely Sometimes Often Daily

Symptoms experienced during high blood sugar

Excessive thirst and frequent urination Fatigue Blurred vision Headache Other

Symptoms experienced during low blood sugar

Shakiness Sweating Confusion Dizziness Other

Physical activity level

Sedentary Light Moderate Active

Smoking status

Never smoked Former smoker Current smoker

Alcohol consumption

Never Occasionally Regularly

Emergency contact name

Nombre

Apellido

Emergency contact phone number

Emergency contact relationship

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