Pre Consultation Information
This form should be filled if you wish to seek Online or Offline consultation with Dr Rajesh Kesari- Consultant Diabetologist, this would provide an insight to him about your condition and severity of disease and its complications,
Patient Information
This would provide some important information about you
Name *
Your answer
Surname *
Your answer
Age ( in Years) *
Your answer
Mobile number
Your answer
Payment Details *
Your answer
Sex
How long you've been suffering from Diabetes? *
Your answer
Occupation *
Recently measured vitals - Pulse / BP/Weight etc
Recently Measured Pulse rate ( Beats / Min)
Your answer
Blood Pressure (mm of Hg) *
Your answer
Weight (in Kgs) *
Your answer
Blood Sugar Fasting
Your answer
Blood Sugar PP
Your answer
HbA1C ( 3 months Avergae)
Your answer
Any other details you wish yo provide about recent tests
Your answer
Family history of the patient
Wether anyone in your family has suffered from the following diseases or conditions- family means real blood relations either from the maternal or paternal side ( Father, Mother, Brother, Sisters, Uncles, Aunts or Grandparents)
Significant family history
Any significant detail which you wish to add about your family history:
Your answer
Personal medical history
History of personal medical conditions, diseases or hospitalization
Any history of regular intake of
Any significant Medical History- wether taking regular medicines for any purpose or Hospitalized for any reason
Your answer
Wether suffering from any problems related to
Significant medical complaints
Significant medical complaints / problems being faced by you, please describe in your own or simple language and refrain from using medical terminology
Your complaints
Your answer
Current Medication and treatment
What medications are you taking, please include all medications even if for some other purpose than diabetes, also include Insulin or any other injections that you may be taking...
Current Medication being taken by the patient
Your answer
Treatment adherence
We wish to know how frequently you take your medicines, exercise and wether you make efforts to control your diet..please truthfully answer these questions as we wish to know the real ground conditions about you
How Frequently do you take medicines / injs *
How Strictly do you control your Diet *
How Active are you physically *
Anything else which you wish to share with us....
Anything that we forgot to ask you but may still be important..
Anything else you wish to add
Your answer
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