Pre-diabetes/Diabetes Form

First name*

Last name*

Email*

Phone*

Has your doctor diagnosed you with pre-diabetes or type 2 diabetes? *

Yes

Do you have a history of hypertension (high blood pressure)? If yes: What was your most recent reading?*

Do you have any other health conditions (heart disease, kidney disease, thyroid issues, digestive disorders)? *

Are you currently taking blood pressure medications (e.g., diuretics, beta-blockers, ACE inhibitors)? *

Are you taking blood sugar medications (e.g., metformin, insulin, GLP-1 agonists)? *

Do you take any supplements (herbal, vitamins, protein powders)? *

Do you follow a specific eating style already (vegetarian, pescatarian, keto, etc.)? *

Do you have a history of fainting, dizziness, or low blood sugar episodes? *

Yes

Do you have a history of uncontrolled blood pressure (consistently 140/90+)? *

Yes

Do you have a history of kidney disease or advanced heart disease *

Yes

Are you taking multiple medications that can interact with diet changes? *

Yes

Are you taking multiple medications that can interact with diet changes? *

Yes

I understand that all programs designed by EQ by Nahla Fitness are meant to provide guidance and support. I know it is not a substitute for medical advice, and I take responsibility for checking with my healthcare provider if I have any concerns about participating.

EQ by Nahla Fitness | 1850 Amsterdam Ave NY, NY 10031 | 347-201-0878

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