Diabetes Type 2

Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

Yes
No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

Yes
No

Unfortunately we cannot proceed with your request based on the information you have provided.

What symptoms have you been experiencing recently?*

Excessive hunger
Excessive thirst
Fatigue or exhaustion
Unexpected weight loss or weight gain
Frequent urination
Blurred vision
Poor wound healing
Other
I don’t have any of these symptoms

If you've listed "other", please explain your symptoms:*

How Long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for asthma?*

Yes
No

How long ago?*

What medications were you treated with?*

Bronchodilator
Steroids
Anti-inflammatory medications

What type of Bronchodilator?*

Ipratropium
Albuterol
Fluticasone/Salmeterol
Salmeterol
Budesonide/Formoterol
Ipratropium bromide/Albuterol
Tiotropium
Levalbuterol

What type of Steroids?*

Pulmicort
Prednisone
Fluticasone
Methylprednisolone
Beclomethasone dipropionate
Flunisolide

What type of Anti-inflammatory medications?*

Zafirlukast
Zileuton

Did treatment work?*

Yes
No

Would you prefer the same treatment?*

Yes
No
Leave to doctor’s discretion

Smoker?*

Yes
No
Never

Alcohol use?*

Any medical family history?*

Yes
No

Please explain your medical family history:*

Do you have any medical conditions?*

Yes
No

Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

Yes
No

Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

Yes
No

Please list any medications, herbals, or supplements:*

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