Medical Assessment for Diabetes

Patient Information
Are you 10-80 years old?

Do you drink alcohol in moderation?

• For men and women - consuming no more than 14 units per week
  • 1 shot of spirits = 1 unit
  • 1 can of beer = 2 units
  • 1 standard glass of wine = 2.1 units

Patient Symptoms
Have you been told by your doctor that you have type 2 diabetes or polycystic ovarian syndrome (PCOS)

OR are you experiencing these symptoms recently?

• Excessive thirst
• Excessive hunger
• Passing more urine than usual
• Unexplained weight loss
• Blurring of vision
• Numbness in your extremities
• Insensitive to pain

Medical History
Do you have any of the following?

• Type 1 diabetes mellitus
• Severe liver disease
• Severe kidney disease

Do you have allergies to metformin?

Are you taking any of these medications?

• Acetazolamide (For glaucoma of the eye, high-altitude sickness)
• Topiramate/zonisamide (For epilepsy/seizure disorder, migraine)
• Dichlorphenamide (For edema/swelling)
• Corticosteroids, like prednisone, dexamethasone (For inflammation)
• Other anti-diabetic drugs, like insulin
• Captopril/enalapril, losartan/telmisartan, and similar drugs (For hypertension)

Consent

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your doctor of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• You will follow up with your doctor for monitoring of blood sugar level and kidney function
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly and that incorrect information can be hazardous to your health
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber