Ruston 318-224-3044 • West Monroe 318-350-6644
COMPREHENSIVE DIABETES ASSESSMENT (PART 2)
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COMPREHENSIVE DIABETES ASSESSMENT (PART 2)
COMPREHENSIVE DIABETES ASSESSMENT (PART 2)
Admin
2017-12-10T01:16:19-05:00
Men Only
Sexual problems:
impotence
loss of libido
other
BEING ACTIVE and OTHER LIFESTYLE HABITS
Do you exercise?
yes
no
Type of:
How often?
How long each time?
OK'd by doctor?
yes
no
Do you smoke?
yes
no
How long?
Number of packs, cigarettes, cigars a day?
Do you drink alcohol?
yes
no
How long?
Number of drinks per week or per day is:
Medications: (list ALL medications; prescription/over the counter & herbals)
Allergies: _________________________________ NAME DOSE (# mg) FREQUENCY (how often)
Verification
Please enter any two digits
*
Example: 12
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