GoMed Diabetes and Hypertension Initiative
Full Name
*
First Name
Last Name
Phone Number
*
A valid phone number is required
Email Address
example@example.com
Address
*
How old are you?
*
Age in years
Gender
*
Please Select
male
female
What is / are your main health condition(s)? You may choose more than one if needed.
*
Diabetes type 1
Diabetes type 2
Hypertension
When were you diagnosed with Diabetes and / or Hypertension?
*
Do you control Diabetes with regular insulin injections?
*
YES
NO
What are your current medications and their prices? (Names, Dosages and Prices)
*
Other underlying health conditions:
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