Diabetes Health & Lifestyle Questionnaire

This form helps us understand your condition so we can recommend supportive herbs and personalize your diet plan. Please answer as completely as you can.

1Patient Details

Full name *

Age *

Sex

Phone

Height (cm)

Weight (kg)

Date of assessment

2Your Condition

Type of diabetes *

Fasting blood sugar (mg/dL)

Post-meal (PP) blood sugar (mg/dL)

Latest HbA1c (%)

How well is your blood sugar currently controlled?

Well controlled Mostly stable Fluctuating Poorly controlled

Do you monitor your blood sugar at home?

Daily Weekly Occasionally Never

3Duration & History

How long ago were you diagnosed?

Approximate age at diagnosis

Family history of diabetes?

Parent(s) Sibling(s) Grandparent(s) None known

Other diagnosed health conditions

4Medication & Treatment

Current diabetes treatment

Oral tablets (e.g. Metformin) Insulin injections Other injectables (e.g. GLP-1) Diet & lifestyle only Ayurvedic / herbal None currently

List all current medications & supplements (name, dose, how often)

Any known drug or herb allergies?

Are you currently pregnant or breastfeeding?

Have you used any herbs / home remedies for diabetes before?

5Diet & Eating Habits

Dietary pattern

Meals per day

Main grain / staple

How often do you eat the following?

Sweets / sugar

Fried / fast food

Fresh fruits & vegetables

Sugary drinks / tea-coffee with sugar per day

Glasses of water per day

Lifestyle habits

Smoking / tobacco Alcohol Often skip meals Late-night eating

Physical activity / exercise

Average hours of sleep per night

Typical day's food (breakfast, lunch, dinner, snacks)

6Current Symptoms

Do you experience low-sugar (hypo) episodes?

Overall energy level lately

7Problems & Concerns

Diabetes-related complications you've been told about

Biggest challenges in managing your diabetes

Controlling cravings Sticking to a diet Remembering medication Finding time to exercise Stress / emotional eating Cost of treatment

Current stress level

Low Moderate High

Digestion / bowel issues?

Your main goals (what would you most like help with?)

Anything else you'd like us to know?

Consent: The information above will be used only to recommend supportive herbs and to personalize your diet plan. Herbal recommendations are complementary and are not a replacement for prescribed medication — please do not stop any medicine without consulting your doctor.

I confirm the above information is accurate and I consent to its use for my care plan. *

This questionnaire is for informational and wellness purposes only and does not constitute medical diagnosis or treatment. Always consult a qualified healthcare professional.