Form: General Medical History
| Question | Response |
|---|---|
| Medical History Verbatim | |
| Approximate start date of condition | |
| Outcome of the condition | |
| Approximate date of recovery from the condition | |
| Severity of the condition |
Form: Diabetes History
| Question | Response |
|---|---|
| Collection Date | |
| Date of Diagnosis of Diabetes? | |
| Type of Diabetes | |
Form: Diabetes Complications
| Question | Response |
|---|---|
| Collection Date | |
| Diabetic Retinopathy | |
| Neuropathy | |
| Nephropathy | |
| Peripheral Vascular Disease | |
| Diabetic Ketoacidosis | |
| Date of Diagnosis | |
Form: General Medical History
| Question | Response |
|---|---|
| Collection Date | |
| Medical History Verbatim | |
| Start Date | |
| End Date | |
| Ongoing | |
Form: Anemia History
| Question | Response |
|---|---|
| Medical Condition | |
| Date of diagnosis | |
| Did the patient have any symptoms of Anemia in | |
| Shortness of breath | |
| Fatigue | |
| Other symptoms | |
| If 'Other', specify | |
Form: Chronic Kidney Diseaase History
| Question | Response |
|---|---|
| Medical Condition | |
| Date of diagnosis | |
| Stage of Chronic Kidney Disease | |
| What is the likely etiology of CKD? | |