Diabetes Questioner Form – Herbal Wisdom Reviews

Please fill out this form to help us assist you better.

First Name *

Last Name *

Email *

Phone Number

Please complete this section carefully to help us assist you more effectively.

1. Can you upload your most recent medical diagnosis or certificate confirming diabetes?

(Purpose: Confirms if it’s Type 1 or Type 2 diabetes and shows current medical supervision)

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

2. What is your most recent HbA1c (Glycated Hemoglobin) test result?

(Purpose: Measures average blood sugar over the past 2–3 months. Important for severity assessment.)

File / Image Upload

Drop your file here or click here to upload You can upload up to 5 files.

3. What are your current fasting blood sugar and postprandial (after-meal) sugar levels?

(Purpose: Indicates daily sugar control and glucose spikes.)

4. Are you currently on any prescribed medications (e.g., Metformin, Insulin)? If yes, list them.

(Purpose: To avoid herb-drug interactions and assess dependency.)

5. Do you have any complications related to diabetes (e.g., vision problems, kidney issues, wounds, and numbness)?

(Purpose: Determines how far the diabetes has progressed in the body.)

6. Have you used any herbal or alternative treatments before? If yes, which ones and for how long?

7. What is your daily diet like? Can you describe a typical day's meals and snacks?

(Purpose: Helps assess sugar intake and dietary discipline.)

8. Do you engage in any regular physical activity or exercise? If yes, how often?

(Purpose: Lifestyle factor crucial for controlling blood sugar.)

9. Do you experience frequent symptoms such as thirst, frequent urination, fatigue, or blurry vision?

(Purpose: Tracks active symptoms to tailor herbal intervention accordingly.)

10. Do you have any other medical conditions (e.g., high blood pressure, cholesterol, ulcers)?

(Purpose: Important to avoid complications.)

Kindly provide the necessary documents OR test result if available:

Medical certificate confirming diabetes diagnosis (from a hospital or lab)

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

Latest HbA1c test report (preferably within last 3 months)

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

Fasting and 2-hours post-meal sugar readings

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

Lipid profile (to assess cholesterol, which is often linked with diabetes)

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

Kidney function test (e.g., creatinine, urea)

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

Eye checkup (retinopathy risk in diabetics)

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

Foot or nerve sensitivity tests (neuropathy risk)

File / Image Upload

Drop your file here or click here to upload You can upload up to 1 files.

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Please fill out this form to help us assist you better.

Please complete this section carefully to help us assist you more effectively.

Kindly provide the necessary documents OR test result if available:

Medical certificate confirming diabetes diagnosis (from a hospital or lab)

Latest HbA1c test report (preferably within last 3 months)

Fasting and 2-hours post-meal sugar readings

Lipid profile (to assess cholesterol, which is often linked with diabetes)

Kidney function test (e.g., creatinine, urea)

Eye checkup (retinopathy risk in diabetics)

Foot or nerve sensitivity tests (neuropathy risk)

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