Final Overweight/Obesity Clinical Trial for Patients with Type 2 Diabetes

1

Are you 18 years of age or older?* This field is required.

Yes

No

2

Do you have Type 2 Diabetes?* This field is required.

Yes

No

I don’t know

3

Are you on a stable dose of at least 1 oral antiglycemic medication?* This field is required.

Yes

No

I don’t know

4

Please select the antiglycemic medications you are currently taking:* This field is required.*select all that apply

Metformin

SGLT-2 Inhibitor

Sulfonylurea

None of the above

5

Is your Body Mass Index (BMI) 25 or greater?* This field is required.

Yes

No

I don't know

6

Calculate your BMI

7

Is your BMI 25 or greater?* This field is required.

Yes

No

8

Does your HbA1c fall between 7% and 10.5%?* This field is required.

Yes

No

I don’t know

9

Have you been informed that you are at an increased risk of any of the following cardiovascular events?* This field is required.*select all that apply

Coronary Heart Disease

Peripheral Artery Disease

Cerebrovasular Disease

Chronic Kidney Disease (CKD)

Congestive Heart Failure (CHF)

I don’t know

Not at an increased risk for a CV event

10

What is your name?* This field is required.

First Name

Last Name

11

What is your phone number?* This field is required.

Please enter a valid phone number.

12

Thank you! We appreciate your time, a study coordinator will be in contact with you soon. If you have any questions, please call Central States Research at (918) 986-2377. Like CSR on Facebook to stay up to date on our enrolling studies:https://www.facebook.com/CSRTULSA