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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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