I8F-MC-GPIL - Pre-screening Form
A study to investigate glycemic control in adults with type 2 diabetes switching to tirzepatide from a GLP-1 RA
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Eligibility Questions
Are you currently diagnosed with Type 2 Diabetes
*
Please Select
Yes
No
What were your most recent hA1C levels?
*
Please check your last lab results if you do not remember.
Have you been on a stable treatment dose of any of these GLP-1 RAs for more than 3 months?
*
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Semaglutide (Ozempic)
None of the above.
What dosage are you currently taking?
Ex. 1.2 or 4.5
Are you currently taking at least 1000 mg/day of any oral antihyperglycemic medication (OAM)?
*
Please Select
None
Sulfonylureas (glipizide, glyburide, gliclazide, glimepiride)
Meglitinides (repaglinide and nateglinide)
BiguanideS (metformin)
ThiazolidinedioneS (rosiglitazone, pioglitazone)
α-Glucosidase inhibitorS (acarbose, miglitol, voglibose)
DPP-4 inhibitors (sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin)
SGLT2 inhibitorS (dapagliflozin and canagliflozin)
Cycloset (bromocriptine)
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