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Control Management Form

First name

Nationality

Age

Gender

Male

Female

Address

Height (cm)

Weight (kg)

Diabetes Information

Diabetes Type

Type 2 Diabetes

Pre-diabetes

Type 1 Diabetes

Not Sure

How long have you had diabetes?

< 1 year

1–5 years

5–10 years

10+ years

Latest HbA1c Value

Fasting Blood Sugar (FBS)

Post-Meal Sugar (PPBS)

Medication & Medical History

Are you currently on diabetes medication?

Yes

No

If yes, which medication?

Other medical conditions?

High BP

Cholesterol

Thyroid

Heart disease

Kidney issues

None

Any diabetes complications?

Neuropathy

Vision problems

Kidney concerns

None

Daily activity level

Sedentary

Moderate

Active

Exercise frequency

None

1–2 times/week

3–5 times/week

Sleep duration

< 5 hours

6–7 hours

7–8 hours

8+ hours

Stress level

Low

Medium

High

Food & Dietary Preferences

Multi choice

Vegetarian

Non-Vegetarian

Vegan

Any food allergies?

Typical daily meals

(Example: breakfast, lunch, dinner, snacks)

Foods you like

Foods you dislike

Goals & Commitment

Are you willing to follow a structured plan for 45 days?

Yes

Maybe

No

Can you cook meals at home?

Yes

No

Phone

Your food choice

Veg

Non Veg

Both

Desired Budget

Get in touch

Connect with our team of expert doctors, psychologists, psychiatrists, nutritionists, physiotherapists, and nursing services at home.

Abu Dhabi – أبوظبي

Dubai – دبي

Sharjah – الشارقة

Ajman – عجمان

Umm Al Quwain – أم القيوين

Ras Al Khaimah – رأس الخيمة

Fujairah – الفجيرة

Email

info@apollocare.ae

Diabetes Information

Medication & Medical History

Other medical conditions?

Any diabetes complications?

Food & Dietary Preferences

Goals & Commitment

Get in touch

Career