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Type 2 Diabetes: Pre-Screening Questionnaire
Name
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Email Address
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Do you have a diagnosis of high cholesterol?
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No
Do you have a diagnosis of high blood pressure?
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No
Do you have a diagnosis of diabetes?
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Yes
No
Are you overweight?
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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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