100% of survey complete.

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1. First name only

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2. Gender

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3. Age

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4. Do you take Lantus daily? (Required.)

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5. If yes to question 4, how much Lantus do you take daily?

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6. Are you taking a short acting insulin? (Required.)

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7. Are you taking any other long acting insulin?

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8. Do you know your hemoglobin A1c (HbA1c or A1c)?

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9. If yes to A1c, please put in most recent value

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10. What medications are you taking for your diabetes? (mark all that apply)

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11. What city are you located in?

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12. Email
(So we can contact you if you're a good fit) (Required.)

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13. Cell Phone number
(So we can contact you if you're a good fit) (Required.)

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