Diabetes Questionnaire

        

                                                                            

                                                                                              

                                                                                              

                                                                                              

                                                                                              

Type of Diabetes (as described by your doctor)              

When was your condition first diagnosed?                         

What was the date and result of your last HbA1C?          

What was the date and result of your last                   
blood glucose test?

Do you regularly test blood and urine for sugar?

As a result of your condition, have you ever had:

High Blood Pressure?                                                             

High Cholesterol?                                                                   

Eye problems?                                                                        

Kidney problems?                                                                   

Heart problems?                                                                     

Diabetic or insulin coma?                                                       
 

Full name:                                                                                        

Phone no:                                                                               

Email address:                                                                        

Best time to be contacted:                                                   

 

Type of insurance you want:

 

 

       

 

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Special Risk Managers Pty Ltd is a member firm and corporate authorised representative of Count Financial Limited ABN 19 001 974 625 AFSL 227232

Date of Birth:
Height:
Weight:
Have you smoked in the last 12 months?