Diabetes Survey

Food Consuming Habits

Rows	Quantity Consumed (in gms/ltrs)	Schedule	Frequency	Consuming Since
Rice
Wheat
Ragi
Jowar
Corn/Oats/Barley/Millets...
Pulses
Cereals
Beans
Spices
Fruits
Citrus Fruits
Dry Fruits & Nuts
Vegetables
Leafy Vegetables
Root Vegetables
Meat/Seafood/Eggs
Edible Oils
Organic Produce
Bakery Products
Process Packed Food (Pickle/Jam/Paste)
Junk Food (Restaurant/Street Food)
Water
Natural Juices
Milk & Milk Products (Paneer/Cheese/Butter/Ghee)
Beverages (Coffee/Tea...)
Cold Drinks (Coke/Cola/Soda)
Beer/Energy Drinks
Wine
Spirits

Exercise & Relaxing Habits

Rows	Exercise Duration (mins)	Intermediate Breaks (mins)	Total Distance (kms)	Schedule	Frequency
Walking
Jogging/Running
Cycling/Climbing
Crunches/Sit-ups
Push/Pull-ups
Weight Exercises
Low (1-5 Kgs)
Medium (5-10 K)
High (> 10 K)
Aerobics/Dancing/Zumba
Yoga
Low (twist, turns, bend, stretch)
Medium (crossing arms & legs)
High (bend backward, lock neck/head)
Meditation
Mind/Puzzle Games
Indoor Games
Outdoor Games
Sleeping
Bowel Movements

Family Medical Status

Medication Level

Rows	Dosage Quantity (MAN or WFM)	Start Date / Month-Year	Medicine Names
Tablets (Morning-Afternoon-Night)
Insulin (Morning-Afternoon-Night)
Dialysis (Weekly-Fortnightly-Monthly)
Any other pre-existing health conditions ?
Treatments & Medicines advised/administered

Latest Medical Test Reports
Rows Part 1 Report Part 2 Report Date / Month-Year
Blood Pressure (High & Low) - BP H&L
Blood Sugar (Fasting & After Food) - BS F&AF
HbA1c & Hemoglobin Levels
Last 6 month's Medical Test Reports
Rows Part 1 Report
Part 2 Report
Date / Month-Year
Blood Pressure (High & Low) - BP H&L
Blood Sugar (Fasting & After Food) - BS F&AF
HbA1c & Hemoglobin Levels
Last 3 years Hospitalization History
Rows Reason Outcome Date / Month-Year
Hospitalization 1
Hospitalization 2
Hospitalization 3
Surgery 1
Surgery 2

Pre-Diabetic Conditions (Measurement & Test Reports)

Rows	Symptoms, Measurement & Test Reports	Date / Month-Year
Height (in cms)
Weight (in kgs)
Eye Sight (Cylindrical Power - Left & Right)
Blood Pressure - BP H&L
Blood Sugar - BS F&AF
HbA1c & Hemoglobin Levels
Symptoms experienced/ing regularly
Any other pre-existing health conditions ?
Treatments & Medicines advised/administered
Hospitalization
Surgery

Post-Diabetic Conditions (Measurement & Test Reports)

Rows	Symptoms, Measurement & Test Reports	Date / Month-Year
Height (in cms)
Weight (in kgs)
Eye Sight (Cylindrical Power - Left & Right)
Highest Blood Pressure (BP - H&L)
Lowest Blood Pressure (BP - H&L)
Symptoms due to BP Fluctuation
Highest Blood Sugar (BS - F&AF)
Lowest Blood Sugar (BS - F&AF)
Symptoms due to BS Fluctuation
Highest HbA1c & Hemoglobin Levels
Lowest HbA1c & Hemoglobin Levels
Symptoms experienced/ing regularly
Reasons Identified for Diabetes ?
Problems/Changes experienced ?
Any other health conditions ?
Treatments & Medicines advised/administered
Hospitalization
Surgery

COVID-19 Test, Treatment & Vaccination Details
Rows Symptoms, Test & Treatment Reports Date / Month-Year
COVID Test
COVID Treatment
Brief COVID Treatment History
Reason for Vaccination Rejection
Vaccine Name
Vaccine Dosage 1
Vaccine Dosage 2
Legal Disclaimer: The data collected of individuals are purely for trial and experimental basis and has no conclusions or implications of medical study or artifacts published by any medical college, university, organization, or agency. The data will be used for only personal study and analysis and will not be shared with any other parties or agencies or sources for any other purpose whatsoever.
Should be Empty:

Rows	Part 1 Report	Part 2 Report	Date / Month-Year
Blood Pressure (High & Low) - BP H&L
Blood Sugar (Fasting & After Food) - BS F&AF
HbA1c & Hemoglobin Levels

Rows	Symptoms, Test & Treatment Reports	Date / Month-Year
COVID Test
COVID Treatment
Brief COVID Treatment History
Reason for Vaccination Rejection
Vaccine Name
Vaccine Dosage 1
Vaccine Dosage 2