Tell us about yourself

1. Have you ever been diagnosed with diabetes?


2. Are you currently on diabetic medication?

3. What is the highest your fasting blood sugar gets when you are on your medication? (mg/dl)

4. Are you currently on insulin?

5. Do you smoke?

6. On a scale of 1-10, with 10 being the highest, how motivated are you to get your diabetic condition under control?

In accordance with federal HIPPA laws, any health data provided here will not be stored or used for any other purpose.  All information provided will be deleted.

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We Look Forward to Seeing You at Our Next Event!