Diabetes Screening Form

Helps healthcare staff identify patients at risk of developing diabetes early on.

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Full name

First Name

Last Name

Email

Phone

Date of birth

Gender

Male Female Other

Family history of diabetes

Yes No

Have you been diagnosed with diabetes?

Yes No

Height (in cm)

Weight (in kg)

Waist circumference (in cm)

Blood pressure (systolic/diastolic)

Random blood glucose (mg/dL)

Fasting plasma glucose (mg/dL)

HbA1c level

Additional information

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