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Clinical Trial for Patients with Type 2 Diabetes
Complete the following questionnaire to see if you may qualify for a clinical trial.
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1
Do you have Type 2 Diabetes?
*
This field is required.
This does NOT include pre-diabetes or gestational diabetes.
Yes
No
I don’t know
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2
Are you currently or have in the past 90 days taken any form of injectable medication for diabetes or weight management?
YES
NO
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3
What injectable medication are you taking?
Insulin
Trulicity
Ozempic
Mounjaro
Other
I'm not taking one
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4
Which oral antihyperglycemic medication are you taking?
*
This field is required.
Metformin
Sulfonylurea (Glipizide, Glimepiride, etc.)
SGLT-2 Inhibitor (Jardiance, Farxiga, etc.)
I'm not sure
I'm not taking one
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5
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
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6
Is your Body Mass Index (BMI) 25 or greater?
*
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Yes
No
I don't know
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7
Calculate your BMI
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8
Is your BMI 25 or greater?
*
This field is required.
Yes
No
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9
Does your HbA1c fall between 7% and 10.5%?
*
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Yes
No
I don’t know
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10
Do you have a medical history of any of the following conditions?
*
This field is required.
*select all that apply
Chronic Kidney Disease (CKD)
Coronary Heart Disease
Peripheral Artery Disease
Cerebrovasular Disease
Congestive Heart Failure (CHF)
I don’t know
Not at an increased risk for a CV event
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11
What is your name?
*
This field is required.
No information will be shared with third party vendors for marketing/promotional purposes.
First Name
Last Name
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12
What is your phone number?
*
This field is required.
By entering your phone number, you consent to receiving calls/and or SMS messages from Central States Research staff. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.
Please enter a valid phone number.
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13
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) 645-5400. Find us on Facebook to stay up to date on our enrolling studies:
https://www.facebook.com/CSRTULSA
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