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Lantidra

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Patient Interest Form

Are you an adult with type 1 diabetes interested in receiving Lantidra? Please complete the Patient Interest Form below.

If you qualify for treatment, a patient screening process will need to be completed. Your medical information will be reviewed by the clinical team at University of Illinois-Health (UIH).

Name (first, last)

Age (must be 18 yrs or older)

Height (in)

Weight (lbs)

What age were you diagnosed with type 1 diabetes?

Have you always required insulin since your diagnosis? *

Yes

How much insulin do you take per day on average (total of all including basal and boluses)?

Do you currently use an insulin pump? *

Yes

Do you currently use a continuous glucose monitor? *

Yes

Do you currently see an endocrinologist or diabetes specialist? *

Yes

What is your most recent HbA1c?

Have you ever tested positive for diabetes antibodies? *

Yes

Are you on any anti-diabetes medications besides insulin? *

Yes

Each month, approximately how many episodes of blood sugar below 55mg/dL do you experience?

Of these episodes, what percent of the time do you have physical or cognitive symptoms alerting you to the low sugar?

In the last 3 years, how many times have you needed help from someone else to treat low blood sugar (e.g., injection of glucagon, bringing food or juice, EMS/911)

Do you currently smoke cigarettes? *

Yes

Thanks for submitting!

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