Metabolic Research Survey

Complete these questions to see if you qualify to participate in a study.

Complete esta breve encuesta para ver si califica

Cuéntenos sobre usted para que podamos encontrar lugares de estudio adecuados cerca de usted. Toda la información que complete permanecerá privada.

Nombre de pila

Apellido

Número de teléfono

Correo electrónico

Street Address

State

Código postal

Sex

Masculino Femenino

Do you consider yourself overweight?

Sí No Do Not Know

Additional Details:

Do you tend to put on weight or carry your weight in your midsection?

Sí No Do Not Know

Additional Details:

Do you know your weight in pounds?

Sí No Do Not Know

Weight (Pounds)

Do you know your height?

Sí No Do Not Know

Pies de altura)

Altura (pulgadas)

Have you ever been diagnosed with high blood pressure?

Sí No Do Not Know

If yes, date:

Do you take any medications for blood pressure?

Sí No Do Not Know

If yes, medication name:

Is the first number in your blood pressure usually above 130?

Sí No Do Not Know

Additional Details:

Is the second number in your blood pressure usually above 85?

Sí No Do Not Know

Additional Details:

Have you ever been diagnosed with type 2 diabetes?

Sí No Do Not Know

If yes, date:

Do you take any medication for diabetes?

Sí No Do Not Know

If yes, medication name:

Have you ever been told that you have pre-diabetes, or are borderline for having diabetes?

Sí No Do Not Know

If yes, date:

Is your fasting blood sugar usually over 100mg/dL?

Sí No Do Not Know

Additional Details:

Have you been told you have visual problems related to diabetes?

Sí No Do Not Know

If yes, what type?

Have you ever been told that you have high cholesterol?

Sí No Do Not Know

If yes, date:

Do you take any medication for cholesterol?

Sí No Do Not Know

If yes, medication name:

Have you ever been told that you have high triglycerides?

Sí No Do Not Know

If yes, date:

Do you take any medication for triglycerides?

Sí No Do Not Know

If yes, medication name:

Have you been told that you have a heart problem?

Sí No Do Not Know

If yes, what type?

If yes, date:

Do your legs cramp if you walk too far?

Sí No Do Not Know

Additional Details:

Do you have tingling or numbness of your feet?

Sí No Do Not Know

Additional Details:

Have you had erectile dysfunction?

Sí No Do Not Know Not applicable, I am female.

Additional Details:

Name of the person who referred you:

Phone number of the person who referred you:

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Participar en investigaciones clínicas

Sea voluntario en la investigación médica en Evolution Research Group para aprender más sobre su condición, obtener acceso a nuevos tratamientos y medicamentos y contribuir a los avances médicos. Actualmente se están inscribiendo estudios en Arkansas. Florida, Ohio, Nueva York y Texas. ¡Busque estudios de inscripción en su área y presente su solicitud para ver si califica!

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Metabolic Research Survey

Complete these questions to see if you qualify to participate in a study.

Complete esta breve encuesta para ver si califica

Participar en investigaciones clínicas

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