Weight Loss Study

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Do You Agree To Proceed?The purpose of this research study TRIUMPH is to investigate the efficacy and safety of LY3437943, an 80-week Phase 3 study in Participants with Type 2 Diabetes Mellitus who have Obesity or Overweight and Obstructive Sleep Apnea. In order to determine if you pre-qualify for this research study, we are going to ask you some confidential questions about your health history and present condition. You do not have to answer any questions that make you uncomfortable and you may stop this interview at any time. Do we have your permission to proceed?
YESNO
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Name* This field is required.
First Name
Middle Name
Last Name
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Referrer
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Your Zip Code* This field is required.
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Street Address
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In order to participate in this study, you must be able to read and write in English or Spanish and sign an Informed Consent/Assent Form prior to any procedures being performed. Women cannot be pregnant or breastfeeding. It is a requirement of this study that you practice effective contraception and use 2 forms of contraception during the study and continue for 60 days after the last dose of study medication.
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What's' Your Date of Birth?* This field is required.Participants Must Be 18 or Over
Month
Day
Year
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What's Your Gender?* This field is required.
Female
Male
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What's Your Gender?* This field is required.
MaleFemale
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Your Height (Inches)
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Your Weight (Pounds)
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What's your Weight and Height?* This field is required.Calculate your BMI
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Do you have a diagnosis of Type 2 Diabetes?
YESNO
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Do you have Obstructive Sleep Apnea?
YESNO
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Are you on a stable treatment for Type 2 Diabetes for at least 90 days? (either diet/exercise alone or up to 3 oral AHMs)
YESNO
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Do you have a history of at least 1 self-reported unsuccessful dietary effort to reduce body weight?
YESNO
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Are you able to self inject yourself and if not, do you have someone toperform injections for you? (Sub.Q-under the skin)
YESNO
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Do you have a self-reported or documented change in body weight greater than 11 pounds within 90 days?
YESNO
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Do you have a prior or planned surgical treatment for obesity?
YESNO
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Do you have a prior/planned endoscopic or device based therapy for obesity? Ex.surgery for obesity-lap band or stapling of the stomach
YESNO
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Do you have obesity induced by other endocrinologic disorders(Cushing Syndrome, monogenetic or syndromic forms of obesity, Prader Willi Syndrome?
YESNO
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Do you have Type I Diabetes or Hx of ketoacidosis/hyperosmolar state/coma/maturity onset diabetes of the young (Chronic Pancreatitis)?
YESNO
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Are you currently receiving or plan to receive treatment for diabetic retinopathy or macular edema?
YESNO
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Do you have a diagnosis or history of cancer within 5 years? Note: Successfully treated Skin / Cervical In-Situ are allowed.
YESNO
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Do you have a hx. of active or unstable major depressive disorder/severe psychiatric disorder such as schizophrenia, bipolar, or other serious mood/anxiety disorder within the last 2 years?
YESNO
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In the past 90 days have you participated in a clinical trial or received aninvestigational product?
YESNO
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Do you have any allergies or adverse reactions to any medications or anything else?* This field is required.
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What medications do you currently take on a daily basis or periodically as needed (Prescriptions or OTC)⇓* This field is required.
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Do you have medical conditions or autoimmune disorders that are or are not being treated with medications? [i.e., Diabetes Mellitus Type I or II, Chronic Pain, High Blood Pressure, Overactive-Bladder, Migraine headaches] * This field is required.
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What's the best time to contact you?* This field is required.This is not an appointment. This is the time that we can contact you.
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What's' Your Phone Number?
Please enter a valid phone number.
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Mobile Number* This field is required.
Please enter a valid cell phone number.
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What's Your Email Address?* This field is required.
example@example.com
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Referrer
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You are about to submit that you would like to volunteer for this weight loss research study. You understand that your information will be sent to our office and a member of our staff will give you a call to confirm your information.
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