Share Your Story About Diabetes

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Please correct the entries below marked with ^*. We either had trouble understanding those fields or need more information. Please fill in all Required Fields.

Basic Information

* Are you filling this out for yourself or on behalf of someone else? * denotes a required field

Please provide the following information about the person with diabetes

* First Name
* Last Name
* E-mail Address
* Confirm E-mail Address
* Address 1
Address 2
* City
* State
* Zip
* Phone (###) ###-####

Demographic Information

* Gender
* Ethnicity
* Date of birth (mm/dd/yyyy)

Related Conditions

	Family History of Type 2 Diabetes. My father, mother and/or one of my grandparents has a history of type 2 diabetes.
	Heart Disease. I have coronary heart disease, atrial fibrillation or another heart condition, OR I've had a heart attack.
	Tobacco. I smoke OR live with someone who smokes tobacco regularly.
	High Blood Cholesterol. My total cholesterol is 200mg/dl or higher.
	Overweight. I am 20 pounds or more overweight for my height and build.
	Lower-Limb Amputation. I have had one or more of my extremities amputated, such as toes or feet.
	Kidney Disease. I have been diagnosed by a healthcare provider with renal disease or end stage renal disease.
	Vision Loss. I have been diagnosed by a healthcare provider with diabetic retinopathy.
	Medications. I am currently on type 2 diabetes medication(s).
If you have checked any of these boxes, please provide us with a detailed explanation of your condition:

* Share Your Story

Don't know what to include in your story? Here are a few ideas:

Tell us about your lifestyle habits before you were diagnosed with type 2 diabetes.
Tell us about when you first learned you had type 2 diabetes. What kind of emotional and/or physical impact did it have on you?
Where do you look for guidance when the going gets tough?
If you could offer advice to someone recently diagnosed with type 2 diabetes, what advice would you give?
How do you manage all your health numbers, including blood sugar, cholesterol and blood pressure levels?
If family and friends have played a part in your success, we want to know.

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Agreement

	* I have read and accept the Terms and Conditions
	Sign up for The Heart of Diabetes, a free program designed to help you learn about the increased risk of cardiovascular disease, due to type 2 diabetes. To learn more about The Heart of Diabetes, visit our Web site.