Metabolic Research Survey
Complete these questions to see if you qualify to participate in a study.
Complete this short survey to see if you qualify
Please tell us about yourself so that we can find suitable study locations near you. All the information you complete will remain private.
First Name
Last Name
Phone Number
Email
Street Address
State
Zip Code
Sex
Male
Female
Do you consider yourself overweight?
Yes
No
Do Not Know
Additional Details:
Do you tend to put on weight or carry your weight in your midsection?
Yes
No
Do Not Know
Additional Details:
Do you know your weight in pounds?
Yes
No
Do Not Know
Weight (Pounds)
Do you know your height?
Yes
No
Do Not Know
Height (Feet)
Height (Inches)
Have you ever been diagnosed with high blood pressure?
Yes
No
Do Not Know
If yes, date:
Do you take any medications for blood pressure?
Yes
No
Do Not Know
If yes, medication name:
Is the first number in your blood pressure usually above 130?
Yes
No
Do Not Know
Additional Details:
Is the second number in your blood pressure usually above 85?
Yes
No
Do Not Know
Additional Details:
Have you ever been diagnosed with type 2 diabetes?
Yes
No
Do Not Know
If yes, date:
Do you take any medication for diabetes?
Yes
No
Do Not Know
If yes, medication name:
Have you ever been told that you have pre-diabetes, or are borderline for having diabetes?
Yes
No
Do Not Know
If yes, date:
Is your fasting blood sugar usually over 100mg/dL?
Yes
No
Do Not Know
Additional Details:
Have you been told you have visual problems related to diabetes?
Yes
No
Do Not Know
If yes, what type?
Have you ever been told that you have high cholesterol?
Yes
No
Do Not Know
If yes, date:
Do you take any medication for cholesterol?
Yes
No
Do Not Know
If yes, medication name:
Have you ever been told that you have high triglycerides?
Yes
No
Do Not Know
If yes, date:
Do you take any medication for triglycerides?
Yes
No
Do Not Know
If yes, medication name:
Have you been told that you have a heart problem?
Yes
No
Do Not Know
If yes, what type?
Have you had bypass surgery or a stent?
Bypass Surgery
Stent
Both
Neither
Do Not Know
If yes, date:
Do your legs cramp if you walk too far?
Yes
No
Do Not Know
Additional Details:
Do you have tingling or numbness of your feet?
Yes
No
Do Not Know
Additional Details:
Have you had erectile dysfunction?
Yes
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:
Okay to receive text messages
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