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Research Participation Survey

First Name:   Last Name:   MI:

Sex: MaleFemale

Contact Information:

Home Phone Number:   Cell Phone Number:

Best time to contact:

Morning (8a - 12p) Late Afternoon (3p - 6p) Afternoon (12p - 3p) Evening (6p - 8p)

Address:

City: State: Zip Code:

Email Address:

Age: Height (Feet & Inches):      Weight (lbs): Date of Birth: mm/dd/yyyy

Do you have Diabetes? YesNo     If yes, what type? Type 1 Type 2 Do you have high blood pressure? YesNo Do you have high cholesterol? YesNo Do you have kidney disease? YesNo Do you have numbness/tingling in your feet? YesNo Do you have family history of diabetes? YesNo Do you have any drug allergies? YesNo Do you have any food allergies? YesNo Do you smoke? YesNo Are you interested in weightloss? YesNo