Patient Registration Form

Registration for Neonatal Diabetes or MODY Diabetes Patients for the Monogenic Diabetes Registry

If you have previously registered and are only submitting updated contact information, please check this box.

After looking at the information about our studies, if you think you qualify and would like to participate, then you should complete the form below. This information will allow us to contact you to clarify your eligibility and guide you through an informed consent process regarding our research.

Please enter as much information as you can and note that you must include at least one phone number or email address through which we will be able to reach you (if you do not have an email address, please call our research team at (773) 702-0829 to register). ALL information is strictly confidential and will not be used for any other purpose than this research study. Your personal information will ONLY be used to contact you regarding aspects of this research, and will NOT be shared with any other parties. This is a SECURE page.

NOTE: If you are a physician/diabetes provider of a patient that you feel may qualify, please direct your patient to this website. DO NOT enter any information about your patient.

*Patient First Name

*Patient Last Name

*Patient biological sex assigned at birth

*Patient Date Of Birth

*Your relationship to patient

Exactly how old was the patient when FIRST diagnosed with diabetes (or blood sugar problem)?
Please enter numerical value only and select the appropriate units

Age at diagnosis of diabetes

Please select units

Days

Weeks

Months

Years

Why do you think the patient might have a monogenic form of diabetes?

Check all that apply:

Diabetes was diagnosed before one year of age

Patient or blood relative has had previous genetic testing confirming a monogenic cause

Incidental diagnosis of mild but persistent high blood sugar that does not worsen over time

Strong family history of diabetes suggestive of direct inheritance through three or more generations

Presumed type 1 diabetes but antibody testing has been negative (GAD65, IA-2, ICA and/or insulin autoantibody tests)

Presumed type 1 diabetes but does not seem to fit the usual pattern (e.g. patient has a detectable C-peptide more than a year after diagnosis, and/or continues to have excellent blood sugars despite being on a very low dose of insulin after the usual honeymoon period)

Presumed type 2 diabetes but does not seem to fit the usual pattern (eg, patient was diagnosed under 30 or so years of age, is not significantly overweight or obese and/or does not have signs of insulin resistance)

The patient's doctor thinks the patient is likely to have monogenic diabetes

Other (please describe below)

* Your First Name

*Your Last Name

Contact Information

Please enter at least one phone number or email address at which we will be able to reach you. If you don’t have an email address, please call the research team at (773) 702-0829 to register.

E-mail Address

Home Phone

Mobile Phone

Work/Other Phone

Address

Address 2

City

State

Please enter 5 or 9-digit zip / postal code.

Zip / Postal Code

Country

If you live outside the 50 United States, then please provide complete address information or clarifications in the comments box below.

Physician or Provider

Please enter information about the doctor or clinician provider currently primarily responsible for the management of the patient’s diabetes.

Name

Address

Address 2

City

State

Please enter 5- or 9-digit zip / postal code.

Zip / Postal Code

Country

Phone

Fax

How did you hear about our research studies?

Check all that apply:

Please provide any details such as which news report you read, which web site mentioned or linked to our studies or which other way you found out about us

Comments or Questions

Please use this space for any clarifications or questions you may have. If the patient is a ward of the state, please give the name and contact information for the person and agency responsible for providing legal consent for any medical procedures or research.

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