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Type 2 Diabetes: Pre-Screening Questionnaire
Name
*
Email Address
*
Phone
*
Do you have a diagnosis of high cholesterol?
*
Select one...
Yes
No
Do you have a diagnosis of high blood pressure?
*
Select one...
Yes
No
Do you have a diagnosis of diabetes?
*
Select one...
Yes
No
Are you overweight?
*
Select one...
Yes
No
Diagnosis of Hypertension
Diagnosis of High Cholesterol
Diagnosis of Diabetes
Mother or Father has a Family History of Heart Disease
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