SPDP          St. Paul's Diabetes  Program   
                                                                                Registration form
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Name *
Age *
Have you been diagnosed as diabetic?  *
Do you have high blood pressure?  *
How many persons live in your home? *
Do you have any other chronic disease? (CKD/COPD)  Please list. *
When was your last doctor visit?  *
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Do you have a glucose monitor?  *
How often do you monitor you blood sugar level?
What was your last blood sugar reading?
What was your last A1c reading?
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