First Name
*
Last Name
*
male female
Street Address
*
City State Zip Code
*   *   *

DOB Height Weight
     

Home Phone Alternate Phone
*  

Current Medication
Diabetes
Have you ever been diagnosed with diabetes? yes no
Type 1 Type 2
Do you monitor your blood sugar? yes no
Are you allergic or sensitive to any medication? yes no
Do you have a history of diabetic ketoacidosis? yes no
Has the dosage of your diabetes medication been stable for >6 months? yes no
Have your non-diabetic medications been stable for >3 months? yes no
Do you have numbness or tingling in your legs and/or feet? yes no
Have you been diagnosed with diabetic neuropathy? yes no
Do you have severe pain with your neuropathy? yes no
Have you had your eyes examined in the last year? yes no
Have you been diagnosed with diabetic retinopathy? yes no
Cardiovascular
Do you have high blood pressure? yes no
Do you have high cholesterol and/or triglycerides? yes no
Have you had any heart problems in the last 6 months? yes no
Do you have Congestive Heart Failure? yes no
Hematology
Do you have any liver disease or blood disorders? yes no
Respiratory
Do you have any respiratory disorders? yes no
Do you smoke? yes no
Cancer
Have you had cancer or malignancy within the last 5 years?
(Except for skin cancer) 		yes no
Women Only
Are you postmenopausal? yes no
Are you practicing any contraceptive methods? yes no
Other
Have you had any major illness or surgery within the last year? yes no
Have you participated in a medical research study within the past 30 days? yes no
Have you been in a research study with our site before? yes no
Please include any other conditions not listed above

Please include any comments or notes

Dallas Diabetes & Endocrine Center  |  7777 Forest Lane, Suite C-685  |  Dallas, TX 75230  |  972.566.7799
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