Contact Information:

* Last Name:

* First Name:

Street:

City:

Postal Code:

Telephone (home):

Telephone (work):

Telephone (mobile):

* E-mail:

Where did you hear about us:

Personal Information

Date of Birth:

Gender:

Height:

Weight:

Would you like to participate in medical studies?

I am still interested in taking part in a study and my details are as follows:

Details on diabetes:

Diabetes diagnosed since:

Therapy with:

Blood sugar value, after fasting:

Date of measured value:

Last HbA1c:

Date of last measurement:

Insulin therapy since:

Insulin therapy with:
(name of medication)

Other insulins used:
(name of medication)

Glucose-lowering tablets:
(name of medication)

I suffer from the following diabetes mellitus-related illnesses and side-effects:

Medication taken on a daily basis:
(including contraceptives)

Allergies: