Medical Evaluation Form - Diabetes Thank you for your interest in our service.In order for our medical team to evaluate whether or not you are eligible for treatment and recommend a relevant medical program and treatment for you, please fill in the form below to the best of your ability or with the help of your physician. Name* First Last Date of Birth* CountryPlease select oneAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweEmail* PhoneHeightUnitCMINCHESWeightUnitKGPOUNDHistory and DiagnosisWhat is your Primary diagnosis?* When were you first diagnosed? MM DD YYYY If you don't remember the specific date, just fill in the year of diagnoses with or without month.Please describe the progression of your condition from early symptoms until now. What is your daily insulin dose? What other medications you are taking to control the blood glucose (dose and response)? Does anyone in your family have medical history relevant to your condition? Type 1 or 2? SymptomsPlease list all your current symptoms: (appetite/performance of daily activities/fatigue/vision/breathing/ chest pain/ headache/ dizziness/ etc.) MedicationsPlease list the medications you are currently taking other than medications you listed above: Except for the insulin and medications, have you taken other medical therapies? If yes, please clarify the treatment, date and results. *Fasting blood glucose, *Random Plasma Glucose, *HbA1c, *C-peptide test, *CTT, Oral glucose tolerance test, Lipid Panel, *Urine Analysis, EKG, and other tests you think it may be relevant. The tests with stars are most need. Please list the diagnostic exams you have had along with date, results and if images are available on request. Any medical records that you can send us will be helpful for your medical evaluation.If possible, please attach to the form below any or all of the following: Blood glucose record (better within one month, with many times records), CPRT〔C-peptide release test 〕, IRT〔 Insulin release test 〕, CTT〔 carbohydrate tolerance test 〕 Kidney and liver function Medical records or recent endocrine evaluation from your endocrionologist FileFileFileFileFileHypertensionNoYesHeart diseaseNoYesPneumoniaNoYesDiabetesNoYesHyperlipidemiaNoYesCVA/ StrokeNoYesLung diseaseNoYesLiver diseaseNoYesKidney diseaseNoYesFracture or breakNoYesCutaneous basal cell carcinoma or in situ carcinomaNoYesCancer or tumorNoYesInflammation or infectionNoYesOthersNoYesPlease explain, give exact diagnosis and date of diagnosis.Other informationIs there a caregiver who can provide you with care and assistance during your stay at the hospital if necessary?NoYesDo you smoke?NoYesAre you currently using or ever used drugs or alcohol?NoYesDo you have sleep apnea, chronic obstructive pulmonary disease or other condition that doesn't allow for general anesthesia?NoYesIf you answered yes to any of the above, please clarify. Validation This is to prevent spam.