50 Year Medalist Update Questionnaire

1. Please enter the following information:
2. Are you male or female?
3. What is your date of birth:
MM DD YYYY
Date:
/
/
4. Please give the year of diagnosis of your diabetes:
Year
Year:
5. What year did you start insulin therapy?
Year
Year
6. What is your height and weight?
FeetInches
Height
7. What is your current weight?
8. Have you ever been/ had:
Yes/ NoYear of 1st timeYear of 2nd timeYear of 3rd time
Diagnosed with coronary artery disease (CAD)?
Diagnosed with congestive heart failure?
Told by a doctor that you had a heart attack or angina?
Told you have had a stroke?
Been hospitalized for a heart attack?
A cardiac bypass surgery?
An angioplasty?
Leg bypass surgery?
A leg artery angioplasty?
9. Have you ever been told you have:
Yes/ NoYear of first diagnosis
Any autoimmune disorder
Thyroid disease (Hashimoto’s, thyroiditis, Addison’s disease)
Celiac disease
Pernicious anemia
Psoriasis
Rheumatoid arthritis
Vitiligo
Myasthenia gravis
Parkinson's disease
Dementia
Alzheimer's disease
10. Would you describe yourself as a "brittle" diabetic?
11. How many episodes of low glucose do you experience in 1 week?
Events
In the first 30 years of your diabetes
In the last 5 years of your diabetes
12. Have you ever gone 3 days or more using less than 10 units of insulin?
13. If yes, have you had these periods in the last 2 years?
14. If yes, have you noticed any other conditions which may coincide with these times?
15. Have you ever had diabetic ketoacidosis after your initial diagnosis?
16. Have you ever stopped taking insulin for a few days after you started insulin therapy?
17. Currently, how many insulin injections do you receive per day?
Number
Injections
18. What is your current daily total insulin dose
19. Do you currently use an insulin pump?
20. If yes, how many years have you used it?
Interval
Time period
21. Please list the type(s) of insulin that you have used throughout your history of diabetes in the chart below:
Types of InsulinTotal Daily InsulinNumber of injections per dayYear began
Before first Medalist Study appointment
1
2
3
After first Medalist Study appointment
1
2
3
22. Have you been hospitalized for treatment of your diabetes, other than the initial diagnosis?
Answer
In the first 30 years of your diabetes
In the last 5 years
23. Have you had any NEW surgeries, diseases, illnesses, or complications since your visit to the Joslin?
24. If yes, please indicate.
Surgery, Illness, Disease or ComplicationYear beganOngoing or year ended
Condition 1
Condition 2
Condition 3
Condition 4
Condition 5
25. In the table below, please check yes or no for each eye-related diagnosis, which eye if known, and year if known.
Yes/ NoIf yes, right or leftYear rightYear left
Any changes from diabetes in your eye?
Injections of medication into your eye for treatment of diabetic eye complications?
Abnormal blood vessels growing in your eye due to diabetes (Proliferative Diabetic Retinopathy)?
Laser treatment for abnormal blood vessels growing in your eye due to diabetes (Proliferative diabetic retinopathy)?
Glaucoma?
Cataract surgery?
Vitrectomy surgery?
Age Related macular Degeneration (ARD)?
Injections of medication into your eye for treatment of age-related macular degeneration?
Leakage or fluid or hard exudates in your retina from diabetes (Diabetic Macular Edema)?
Other eye problem or eye procedure/surgery?
26. Please list the NEW medications and vitamins that you have started since your last Medalist Study visit:
27. Is there anything else you would like to share with us?
28. Would you like more information from us:
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