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　　1 Electronic patient statement explainations:
　　1) Electronic patient statement is established for easy communication between patients and doctors through the internet. The specialist group will consult the patient statement as soon as possible since it is submitted.
　　2) Consulting Tel：0086-10-6585 6666
　　3) Please fill in all forms accurately in order to analyses the case for you by the doctors.
　　2 Personal information：

Name 　 Sex 　Age　
Tel
Zip code
Address
Email

Years of Diabetes

　　3 Basic information about diabetes
1)Food intake fried foods times/week） spicy food
vegetarian hot food others
2)Fluid intake drinks ml/day or drinks bottle/day；
urinate in night times、total urine ml/24hours
3)Exercise
never less than 3times/week more than 3times/week
Types

（1）Aerobic exercise
slow running walk dance swim
hiking Chinese Gongfu
（2）Anaerobic exercise
running basketball volleyball
football ntensive exercise
Time 20minutes 40 minutes fixed time
non-fixed time
4)Glucose monitoring： occationally non-fixed time fixed-time
never
5)Receive diabetes education from： medical staff newspaper other media
friend seminar　 times/year
Initial symptom of diabetes：
Excessive thirst
Extreme hunger
Frequent urination
Weight loss
Obese
Fatigue
Constipation
Abdomen pain
Headache
Blurry vision
Skin itch
Dry skin
Numb
Abnormality of menstruation
Impotence
Diarrhea
Cardiovascular diseases
Peripheral neuropathy
Liver or kidney disease
History either present or in past：
Hypertension
Arteriosclerosis
Smoke
Rheumatic heart disease
Eat Fried food
Drink alcohol
Eat Spicy food
Families history
Diagnosis
Drugs ever used before
Medication/ day
Breakfast Lunch Dinner
Dose:
Obese
Normal
Slim
Blood glucose
Urine glucose
Protein in urine
Ketoacidosis
Insulin
C-peptide
Date
Others
Clinical classification：
Diagnosis：
IDDM
NIDDM
What is your question?
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Address: No.1 Tianshuiyuan East Street, Chaoyang District, Beijing 100025 P.R.China
Diabetes Consulting Tel: 0086-10-65856666 Tel:0086-10-65856666
E-mail :info@bcdh.cn
Web Site : http://www.beijingdiabetes.com | www.diabetes-hospital.com | www.bcdh.cn