NADI - National Diabetes Institute, Malaysia

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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

Stopped years

Section D

D. Would you like to receive regular updates from NADI?

Yes

Section E - Optional

E. Your family doctor details

Name

Address

Tel. No.

Code:


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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