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First Name
Last Name
Address
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To help us offer you appropriate information, coupons and samples, please tell us about yourself:
How long have you had diabetes?
1 month Less than 1 year 1 to 2 years 3 to 5 years More than 5 years
Gender
Male Female
Age
17 and under 18 to 34 35 to 49 50 to 59 60 plus
How do you manage your diabetes?
Insulin Injections Insulin & Oral Medication Insulin & Diet Oral Medication Oral Medication & Diet Diet/Exercise
How often do you test your blood?
Daily Weekly
