* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download the T1D patient information form as a
Survey
Document related concepts
Transcript
Faustman Lab Pre-Appointment Information Form (TYPE 1 DIABETICS AND CONTROLS ONLY) Thank you for taking the time to fill out this form which will help us prepare all the necessary paperwork for your appointment. This form will NOT be used for any screening purposes, and is only intended to aid in the process of preparing the paperwork for your visit to the lab. Patient name: ________________________ Date of birth: ___________ Sex: M/ F Parents’ names if patient is a minor: __________________________________________ Address:________________________________________________________________ City/State/Zip Code: _______________________________________________________ Home Phone: ___________________ Work Phone: ___________________ Ethnicity (choose one) Hispanic or Latino Not Hispanic or Latino Prefer not to answer Cell Phone: __________________________ E-mail: _____________________________ Race (choose one) American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White More than one race Prefer not to answer List medical history: _______________________________________________________________________ _______________________________________________________________________ Do you have Type 1 diabetes? Yes/No If yes, please fill out the lines directly below. Age of diabetes onset: _____________ Have you been diagnosed with any of the following diabetic complications? Retinopathy Neuropathy Foot ulcers Amputations Kidney disease (nephropathy) or Microalbuminuria Stroke Heart disease (including artery disease) Y Y Y Y Y Y Y N N N N N N N List current medications and dosage: Medication Dosage Are you or your child interested in: Giving a research blood sample? Participating in future phases of our trial? Supporting our research by making a donation? Assisting with our fund-raising efforts? Please send this completed form to: Email: [email protected] Fax: 617-726-4095 Mail: Dr. Denise Faustman Massachusetts General Hospital Immunology Lab – Diabetes Research CNY, 13th Street, Building 149, Room 3603 Charlestown, MA 02129 Medication Dosage Yes No