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

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?

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

Participate in Clinical Research

Volunteer for medical research at Evolution Research Group to learn more about your condition, gain access to new treatments and medications, and contribute to medical advancements. Studies are now enrolling in Arkansas. Florida, Ohio, New York, and Texas. Browse enrolling studies in your area and apply to see if you qualify!

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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

Participate in Clinical Research

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