Clinical Trial for Patients with Type 2 Diabetes and Excess Weight

1

Do you have Type 2 Diabetes?* This field is required.This does NOT include pre-diabetes or gestational diabetes.

Yes

No

I don’t know

2

Are you currently or have in the past 90 days taken any form of injectable medication for diabetes or weight management? (Insulin, Trulicity, Ozempic, Mounjaro, etc.)

YESNO

4

Which oral antihyperglycemic medication are you taking?* This field is required.

Metformin

Sulfonylurea (Glipizide, Glimepiride, etc.)

SGLT-2 Inhibitor (Jardiance, Farxiga, etc.)

I'm not sure

I'm not taking one

5

Please select the antiglycemic medications you are currently taking:* This field is required.*select all that apply

Metformin

SGLT-2 Inhibitor

Sulfonylurea

None of the above

6

Is your Body Mass Index (BMI) 25 or greater?* This field is required.

Yes

No

I don't know

7

Calculate your BMI

8

Is your BMI 25 or greater?* This field is required.

Yes

No

9

Does your HbA1c fall between 7% and 10.5%?* This field is required.

Yes

No

I don’t know

10

Do you have a medical history of any of the following conditions?* This field is required.*select all that apply

Chronic Kidney Disease (CKD)

Coronary Heart Disease

Peripheral Artery Disease

Cerebrovasular Disease

Congestive Heart Failure (CHF)

I don’t know

Not at an increased risk for a CV event

11

What is your name?* This field is required.

First Name

Last Name

12

What is your phone number?* This field is required.

Please enter a valid phone number.

13

Thank you, we appreciate your time! A study coordinator will be in contact with you soon. If you have any questions, please call Central States Research at (918) 645-5400. Find us on Facebook to stay up to date on our enrolling studies:https://www.facebook.com/CSRTULSA

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