| |
Yes |
No |
|
1. History of
Diabetes in the family? |
□ |
□ |
|
2. Are you
over 40 years old? |
□ |
□ |
|
3. Are you
over weight? |
□ |
□ |
|
4. Do you eat
more than people of your age? |
□ |
□ |
|
5. Do you feel
thirsty more than other people? |
□ |
□ |
|
6. Do you pass
urine more frequently? |
□ |
□ |
|
7. Do you feel
run down and tired easily? |
□ |
□ |
|
8. DO you get
boils or sores on your body? |
□ |
□ |
|
9. DO you get
boils or sores on your body? |
□ |
□ |
|
10. Have you
changed glasses more frequently? |
□ |
□ |
|
11. Any loss
of weight lately? |
□ |
□ |
|
12. Women:
Were your babies over-weight at birth? |
□ |
□ |
|
13. Women: Do
you have vaginal itching? |
□ |
□ |
