I8F-MC-GPIL - Pre-screening Form

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 NameLast Name
Date of Birth*

MonthDayYear
Date
Gender
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Eligibility Questions
Are you currently diagnosed with Type 2 Diabetes*
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)?*
Should be Empty:

Eligibility Questions