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Diabetics Online Registration

 
Section A
Prefix:
*   If others
Name: * 
I/C No.:
Address: *
 
Town/City: *
Postcode: *
State: *
Tel No. (home):
Tel No. (handphone): *
Email: *
Username: *
Password: *
 
Section B
B1. Date of Birth: * 
B2. Gender: *
B3. Ethnicity: *
 
Section C
C1. Age upon diabetes diagnosis:
C2. Do you have any complications of diabetes:
Yes No Do not Know
If yes, please indicate
heart feet eyes
leg ulcers amputations kidneys
others, please specify
C3. What is your present treatment?
exercise diet
weight control tablets
insulin others, please specify
 
C4. Do you have other associated conditions?
overweight high blood cholesterol
high blood pressure none
C5. Do you smoke?
Yes No Stopped years
 
Section D
D. Would you like to receive regular updates from NADI?
Yes No
 
Section E - Optional
E. Your family doctor details
Name
Address
Tel. No.
 
Code:
 Turing Number
Please enter the sequence of numbers as displayed in the right picture.
   
  * Must be completed
  I have read and agree to all terms and conditions

 
 






 
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