DiabetesClinicalTrial



		
	

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Patient Pre-Screener

To see if you might qualify for this clinical trial and to be referred to the local trial center in your area, please take a moment to complete the questionnaire below.

There’s No Obligation

Completing the questionnaire does NOT obligate you to participate in the trial. Your answers help to determine if you are a candidate for the trial. If you pass the online pre-screener you may be contacted, with your permission, by a local trial coordinator or a trial representative. Representatives may contact you by telephone, email, or text. Message and data rates may apply.

1) Have you been diagnosed with:

Type 2 Diabetes

Type 1 Diabetes

Gestational Diabetes

Pre-Diabetes

Not Diagnosed with any Diabetes condition

This is a required question. Please answer and resubmit.

2) How long have you been diagnosed with the above Diabetes condition?

0-3 months

4-6 months

7-12 months

12+ months

Not Applicable

This is a required question. Please answer and resubmit.

3) For the past 3 months, please select any medications you have been using to treat your diabetes. (Select all that apply. Click the "?" icons to view complete list of medications in each category.):

Metformin ?

Oral medications besides metformin ?

Injectable (non-insulin) medications ?

Insulin ?

Not taking any medications

This is a required question. Please answer and resubmit.

Metformin drugs include:

  • Glucophage®
  • Glucophage XR®
  • Glumetza®
  • Fortamet®
  • Riomet®

Oral medications other than Metformin include:

  • Other metformin combination drugs
  • Amaryl® (glimepiride)
  • Glucotrol® or Glucatrol XL (glipizide)
  • Micronase® or Diabeta (glyburide)
  • Glynase® (micronized glyburide)
  • Diabinese® (chlorpropamide)
  • Tolinase® (tolazamide)
  • Orinase® (tolbutamide)
  • Januvia® (sitagliptin)
  • Onglyza® (saxagliptin)
  • Trajenta® (linagliptin)
  • Nesina® (alogliptin)
  • Avandia® (rosiglitazone)
  • Actos® (pioglitazone)
  • Farxiga® (dapagliflozin)
  • Invokana® (canagliflozin)
  • Jardiance® (empagliflozin)
  • Any other oral medication you take for diabetes that may not be listed here.

Injectable (non-insulin) medication examples include:

  • Victoza® (liraglutide)
  • Byetta® (exenatide)
  • Bydureon® (exenatide extended-release)
  • Trulicity® (dulaglutide)
  • Adlyxin® (lixisenatide)
  • Ozempic® (semagludtide)
  • Soliqua® (insulin glargine / lixisenatide)
  • Xultophy® (insulin degludec / liraglutide)

Insulin medication examples include:

  • Humalog® (insulin lispro)
  • Novolog® (insulin aspart)
  • Apidra® (insulin glulisine)
  • Humulin® R / N
  • Novolin® R / N
  • Lantus® (insulin glargine)
  • Basaglar® (insulin glargine)
  • Levemir® (insulin detemir)
  • Symlin® (pramlintide)
  • Tresiba® (degludec)
  • Toujeo® (insulin glargine 300 U)
  • Fiasp® (insulin aspart injection 100U/mL)
  • Afrezza® (insulin) inhalation
  • Soliqua® (insulin glargine & lixisenatide)
  • Xultophy® (insulin degludec & liraglutide)

4) What is your current height and weight?

Height:

Weight:

This is a required question. Please answer and resubmit.

5) Have you recently been tested for you HbA1c (or A1c) levels?

6.9% or lower

7.0% to 7.9%

8.0% to 8.9%

9.0% to 9.9%

10% or higher

No / Not sure

This is a required question. Please answer and resubmit.

6) What is your year of birth (example: 1975)?

This is a required question. Please answer and resubmit.

7) How would you describe yourself?

White or Caucasian

Black or African American

Hispanic or Latino

Asian

Native American

Pacific Islander

Prefer Not to Answer

Unknown

This is a required question. Please answer and resubmit.

8) Have you been diagnosed with moderate Chronic Kidney Disease or renal impairment (CKD stage 3 or 4), or have you been seen recently by a kidney specialist?

Yes

No

Not Sure

This is a required question. Please answer and resubmit.

9) What is your ZIP / postal code?

This is a required question. Please answer and resubmit.

Press button only once to avoid multiple submissions.