Diabetes Assessment
Name
*
First Name
Last Name
Email
*
example@example.com
Diabetes Symptoms
Diabetes Risk Factors
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Have you noticed an increase in your thirst?
*
Yes
No
Do you find yourself urinating more frequently?
*
Yes
No
Have you experienced unexplained weight loss recently?
*
Yes
No
Are you often feeling unusually tired or fatigued?
*
Yes
No
Have you noticed any changes in your vision (e.g., blurriness)?
*
Yes
No
Have you noticed any wounds or sores that are slow to heal?
*
Yes
No
Do you experience frequent infections or have skin conditions that won't go away?
*
Yes
No
Do you often notice a tingling sensation or numbness in your hands or feet?
*
Yes
No
Do you feel unusually hungry, even after eating?
*
Yes
No
Is there a history of diabetes in your family?
*
Yes
No
Have you been diagnosed with Polycystic Ovary Syndrome (PCOS) or another condition that increases the risk of diabetes?
*
Yes
No
Do you have high blood pressure or high cholesterol?
*
Yes
No
Do you struggle to manage a healthy weight?
*
Yes
No
Is your physical activity limited?
*
Yes
No
Are you 45 years old or older?
*
Yes
No
Symptoms Level
Risk Level
Submit
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