Patient Registration Form

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


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. 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 Gender	MaleFemale
* Patient Date Of Birth
* Your relationship to patient
* Specify Other
Exactly how old was the patient when FIRST diagnosed with diabetes (or blood sugar problem)? For example '3 months old’ or '36 years old'.”
Age at diagnosis of diabetes

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

Please enter at least one phone number or email address at which we will be able to reach you.
E-mail Address

Please enter only a 10-digit phone number, without a 1 at the beginning, for example: 773-702-0829, 7737020829 or (773) 702-0829

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

Please enter only a 10-digit phone number, without a 1 at the beginning, for example: 773-702-0829, 7737020829 or (773) 702-0829

Phone
Email

How did you hear about our research studies?
Check all that apply:

My doctor/diabetes provider Web Searching A News Report A friend or family member Other/describe

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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Visit the Kovler Diabetes Center Website

Monogenic Diabetes

The University of Chicago Kovler Diabetes Center

Patient Registration Form

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

Contact Information

Physician or Provider

How did you hear about our research studies?

Comments or Questions