Diabetes Screening Questionnaire

AyurVAID Hospitals is now a part of Apollo Hospitals Group.

Fill the Following Form

Test DSQ Form on Website

Patient Id

First Name

Last Name

PP Name

Gender

Are you a Diabetic ?

AVH center

Section 1: If YES, fill sections 1 and 3. If NO or DON'T Know, then fill sections 2 and 3

Choose type of diabetes

At what age were you diagnosed? (in yrs.)

What is your current HbA1c Score?

What is your current FBS Score?

What is your current diabetes management? (You may select multiple options)

Mention other medications if any

Your Satisfaction with current Treatment

What are the difficulties faced currently by you?

Mention other difficulties faced if any

SECTION 2: DETERMINE YOUR DIABETES RISK

1. Age

2. Waist Circumference at Umbilicus (at widest part of abdomen)

3. Family History

4. Physical Activity Level

5.A. Excess Food Intake

5.B. Food Type

6. Other Factors (Select any/all that is applicable)

a) Diagnosed with Heart problem

b) Diagnosed with Hypertension/high TGL/low LDL

c) Diagnosed with PCOS or irregular menstruation or Gestational Diabetes?

d) Diagnosed with Hypothyroidism?

e) Previous positive Impaired Glucose Tolerance (IGT)?

f) Have you consumed any antipsychotic medicine or corticosteroids or Diuretics for more than 2-6 months?

g) Have you had your menopause/Hysterectomy with or without removal of ovaries

SECTION 3: ASSESS THE SEVERITY OF DIABETES SYMPTOMS / PRESENCE OF EARLY WARNING SIGNS OF DIABETES

LETHARGY

a) Do you feel tired even without much exertion?

b) Do you often feel mentally dull/lazy?

c) Often desire to sit, sleep, lie down?

URINE

d) Turbid and fruity odour to urine?

e) Milky white colour of urine / frothy

f) Quantity of urine / micturition proportionate with fluid intake?

g) History of repeated urinary infective conditions / abnormalities?

h) Frequency of urination (Choose from i/ii/iii # of times in Daytime (D) and Night-after going to bed (N))

PHYSIOLOGICAL STATUS

i) Sweet taste in mouth?

j) Body odour?

k) Mouth dryness / throat dryness?

l) Burning sensation in palm/sole?

m) Excessive thirst / water intake? (> 2L/day)

n) Excessive food intake/eating?

o) Excessive sweat?

p) Desire for cold?

q) Bad breath?

PHYSICAL STATUS

r) Fast growth of nails and hair?

s) Body heaviness?

t) Sticky and knotty hair?

u) Stickiness in eyes / ears / teeth / tongue etc

v) Looseness or flaccidity in the body

w) Unexplained Weight gain or loss during last three months even without change in food habits or exercise/activity pattern?

NUMBNESS / Non Healing wound or ulcer

x) Numbness in both hands and/or both soles?

y) Numbness Whole body?

z) Non healing wound / ulcer?