Study (YQAB) Eligibility Questionnaire
Thank you for your interest in this clinical research study! To help us determine if you may be eligible, please answer all of the questions below. This should take less than 2 minutes. All questions require a YES or NO answer. Please answer each question honestly - there are no wrong answers. Your responses are confidential and will only be used to assess potential eligibility for this study.
First name
*
Middle name
Last name
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are you 18 years of age or older?
*
Yes
No
Have you been diagnosed with type 2 diabetes?
*
Yes
No
Is your most recent HbA1c (A1C) between 6.5% and 10.5%? (If you are unsure, select YES and we will check this at your screening visit.)
*
Yes
No
Is your body mass index (BMI) 27 or above? (If you are unsure, select YES and we will check this at your screening visit.)
*
Yes
No
Height
Weight
BMI
What type of stable diabetes treatment are you currently using?
Diet and exercise alone
1–3 oral diabetes medications
Diet/exercise plus 1–3 oral diabetes medications
List Medications Here
Have you taken any GLP-1-based medication - including pills or injections such as Ozempic, Wegovy, Rybelsus, Mounjaro, Zepbound, Trulicity, or Foundayo - in the past 3 months?
*
Yes
No
Have you had bariatric surgery for the treatment of obesity?
*
Yes
No
Have you participated in another research study or received an investigational treatment?
*
Yes
No
Study name
Intervention
Current participation or treatment status
Start date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last dose or treatment date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End or withdrawal date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Information:
Submit
Should be Empty: