Would you like to register to be a part of the

?

Please select one...

If YES, please scroll down to continue your registration.

If NO, please exit page or contact us for more information. 

One last question before we begin...

Have yOU READ

and do you understand what the registry is?

Please read all of the information about the registry BEFORE your register. 

Introduction Questions

Are YOU living with Type 1 Diabetes?

ARE YOU OVER 18 years of age?

Type 1 Diabetes Details

Please answer the questions below with the personal details of the person living with Type 1 Diabetes. 

PATIENT NAME

GENDER

DATE OF BIRTH

COUNTRY OF BIRTH

DATE OF TYPE 1 DIABETES DIAGNOSIS

I do not remember the date of diagnosis

MARITAL STATUS

MAILING ADDRESS

PHONE NUMBERS

EMAIL ADDRESS

ARE YOU AT SCHOOL?

IF YOU ARE A STUDENT,WHAT's THE NAME OF YOUR SCHOOL?

IF YOU ARE WORKING, WHAT'S YOUR OCCUPATION?

WHO IS YOUR DOCTOR?

If you do not have a doctor that you regularly see for your Type 1 Diabetes, please type "NONE" in the box below. 

WHEN DID YOU LAST SEE YOUR DOCTOR?

If you do not remember the last time you saw your doctor, please type I DONT KNOW, in the box below. 

WHAT TYPE OF INSULIN DO YOU USE?

Humulin N

Novolin N

70/30 Mixed Insulin

Humulin R

Novolin R

Levemir

Lantus

Apidra

Novorapid

DO YOU USE AN INSULIN PEN?

DO YOU USE AN INSULIN PUMP?

HOW CAPABLE DO YOU THINK YOU ARE IN MANAGING YOUR DIABETES?

Please slide the scale to your answer below. 

NOT CAPABLE

VERY CAPABLE

HOW Educated are you about type 1 DIABETES?

Please slide the scale to your answer below. 

I DONT KNOW MUCH

VERY EDUCATED

Signed Consent

confirm that all of the information above is correct 

to my knowledge. 

I give The Ian Woosnam Type 1 Diabetes Registry permission to contact me or my doctor and send me Newsletters, Surveys, Updates and Diabetes Related Information.