Diabetes Volunteer Form

Name*

First Name

Middle Name

Last Name

Home Phone*

Work Phone

Email*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Age*

Height

Date of Birth*

Weight

Pounds

Diabetes Type*

Type 1 Type 2 None

How long have you had diabetes?

Do you take insulin?

Yes No

Please list your average dose:

Do you take diabetes pills?

Yes No

Please list diabetes medication(s) and dose:

What is your average Fasting Blood Sugar?

What was your last HbA1c?

Do you feel numbess, tingling, or burning in you feet or legs?*

Yes No

Comments

I have completed this form myself and wish to be contact about ongoing or future studies being conducted at the Strelitz Diabetes Center. My information will not be sold or disclosed without my permission.

Please enter your name to confirm submission.