Type 1 Diabetes Questionnaire

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

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Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

SiteId

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Have you had Type 1 diabetes for at least 3 years? (Type 1 diabetes is when your body does not make insulin and you need insulin every day.)

Do you currently take insulin using shots or an insulin pump?

Do you use a continuous glucose monitor (CGM) to check your blood sugar? (For example: Dexcom, Medtronic, or FreeStyle Libre.)

In the past 2 months, have you had a low blood sugar episode? (Low blood sugar can cause sweating, shakiness, anxiety, a fast heartbeat, dizziness, or may have shown as low on your glucose monitor.)

Are you currently taking any diabetes or weight-loss pills or injections? Please select all that apply:

Eligibility Status