Diabetes and Glandular Disease Research - San Antonio, TX  

Research Participation Survey

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Last Name     

First Name    

Sex                 Male          Female

Best phone number to reach you (area code and number)

Best times to reach you      

Address   

City                

State                  

Zip                                                   

Email Address       

Are you currently in any study?      

    Yes            No

If yes, what is its name?   

Are you Diabetic?   

    Yes        No

If yes, when were you diagnosed (month and Year)   

Type of Diabetes:

        Type 1                          

         Type 2 (Insulin)         

         Type 2 (Oral)              

                                                      Type 2 (combo-pill and insulin)                       

           Type 2 (Diet)             

           Not a Diabetic          

 

Medications you are taking:   

Number of Insulin shots per day   

Dose           

Sugar Range   

Your Age   

Date of Birth   

Height    

Weight   

Do you use tobacco products?   

    Yes        No

What Type?   

If yes, how many each day?   

If you used tobacco products in the past, when did you quit?       

Do you drink alcoholic drinks?

  Yes        No

If yes, how many drinks per week?   

The following information is about medications you are taking for conditions other than diabetes. If you indicate "yes" to any of the following, please put the name of the medication in the designated box.

Are you using birth control methods?

    Yes     No     N/A   

Are you taking estrogen or testosterone?

    Yes        No  

Do you have high blood pressure?

    Yes        No

Do you have heart disease?

    Yes        No   

Do you have circulation problems?

    Yes        No

Do you have high cholesterol or high triglycerides?

    Yes         No

Do you have depression?

    Yes        No

Do you have asthma?

    Yes        No

Do you have cancer?

    Yes        No

Type        Year diagnosed   

Have you ever had cancer in the past?

    Yes        No

Type         Year diagnosed   

Do you have a history of a stroke?

    Yes        No

Do you or have you had seizures?

   Yes        No

Do you have anemia?

    Yes        No

Do you have foot ulcers or foot pain?

    Yes        No

Do you have stomach problems?

    Yes        No

Do you have arthritis?

    Yes        No

Do you have kidney disease?

    Yes        No

Do you have eye abnormalities?

    Yes        No

Do you have liver disease?

    Yes        No

Do you have thyroid condition?

    Yes        No

Do you have a history of using steroids?

Yes        No

Have you been hospitalized in the past two years?

Yes        No    Year        Condition   

Please include any other medications or conditions not listed above:

Please include any comments or notes which may be relevant:

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