Diabetes

Diabetes causes the body to be unable to control the sugar levels in your blood. High levels of circulating sugar in the body cause damage to blood vessels and nerves, which result in heart attacks, strokes and blindness. This questionnaire is designed to help you and your physician identify whether you are currently showing any signs of Diabetes or wheather your lifestyle could contribute to the onset of diabetes. This questionnaire does not replace regular visits to your doctor for diabetes screening but merely lists factors, which could be indicative of diabetes.

Each question has several responses from which you are asked to choose the one that best describes your own situation. Please be sure that you select only one response per question.


Please ensure all information is completed correctly in order for us to respond to your assessment promptly.

Your Name (required):

Your Email (required):


QUESTION 01:
Is anybody in your family suffering or has anyone suffered from diabetes?

QUESTION 02:
Are you overweight? (Take you length in centimetres and subtract 100). That is your target weight.

QUESTION 03:
Do you have high cholesterol?

QUESTION 04:
Do you have high blood pressure?

QUESTION 05:
Do you sweat a lot?

QUESTION 06:
Do you exercise regularly?

QUESTION 07:
How many times do you urinate at night?

QUESTION 08:
How often do you get very hungry?

QUESTION 09:
How often do you get very thirsty?


Submit your self assessment form to the Mens Clinic International Doctor for evaluation: