Contents

1. Basic Information

2. Personal Health History

3. Health Habits/Safety

4. Family Health History

5. Final Health Questions



YOUR RESPONSES ARE STRICTLY CONFIDENTIAL

We will never sell, give, rent, lend, or in any other way disclose your email address or personal information to anyone outside of Diabetics 4 Diabetics for any reason other than a duly obtained court order. All infor- mation you provide to Diabetics 4 Diabetics will only be used by us solely to help us meet your needs.
Step One: Basic Information


Your Name:
        
 Prefix First NameM.I. Last NameSuffix

AKA Name:
    Sex:
Please indicate if you have any other legal or a former name.

Birth Date:
- - Marital Status:
MonthDayYear

Address:

Street address or PO Box
   
CityStateZip Code

Home Phone:
- - Work Phone: - -


Occupation:
Employer:


Insurance:

Please enter the name of your medical insurance carrier (if you have coverage).

Your E-mail:

If you have more than one email address, enter the one you'd like us to use.


Press Continue to proceed to the Personal
Health History form on our secure server.




Copyright 2003 - Diabetics for Diabetics and EB Communications