Lifescan!

NamVet - 21894
By NamVet - 21894 Latest Reply 2008-10-20 06:20:58 -0500
Started 2008-10-20 06:20:58 -0500

Note: The information you submit will be governed by our site's Privacy Policy. Unless you choose to receive additional information from us by checking the box below, it will be used only to determine whether you qualify for this offer.

Do you have diabetes?
Yes
No

What is your relationship to the person with diabetes?
Myself
Partner/Spouse
Friend
Relative
Parent
Healthcare professional
I have pre-diabetes
I don't have diabetes and I'm not calling for someone with diabetes
I am a Professional Caregiver


Title:
Mr. Ms. Mrs. Miss

First Name:

Last Name:

Suffix:
Select a Suffix Sr. Jr. II III IV Child
Address:


City:

State:
Select a State Alabama Alaska American Somoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:

Phone:
Example: XXX-XXX-XXXX

Date of Birth:
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894 1893 1892 1891 1890
E-mail:

If you do not have diabetes yourself, but care about someone who does, answer with this person in mind.

When were you diagnosed with diabetes?
Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894 1893 1892 1891 1890

What is the name of the blood glucose Meter that you use most often to test your blood glucose levels?
Select OneTouch Ultra2 OneTouch UltraSmart OneTouch Ultra-Link OneTouch Select OneTouch UltraMini OneTouch Ultra OneTouch Basic OneTouch FastTake OneTouch Profile OneTouch SureStep OneTouch II OneTouch (Other) BD Logic Accu-Chek Active Accu-Chek Advantage Accu-Chek Aviva Accu-Chek Compact Accu-Chek Compact Plus Accu-Chek (Other) FreeStyle (TheraSense) FreeStyle Flash FreeStyle Freedom Lite TheraSense (Other) FreeStyle Freedom FreeStyle Lite Precision Xtr (MediSense) Precision Q.I.D. (MediSense) MediSense (Other) Glucometer Elite/Elite XL Glucometer DEX/DEX II Bayer (Ascensia) Elite/Elite XL Bayer (Ascencia) DEX/DEX II Bayer (Ascensia) Breeze Bayer (Ascensia) Contour WaveSense Jazz WaveSense Keynote Bayer (Ascensia) Breeze 2 Glucometer/Ascensia (Other) Prestige Smart System TrueTrack Smart System Reli-On Other Unknown Do Not Use a Meter

How long have you had your Meter?
Select Less than 1 year 1 Year 2 Years 3+ Years Do not use a meter

How often do you test your blood glucose?
Select Unknown 4+ times per day 3 times per day 2 times per day 1 time per day 4-6 times per week 1-3 times per week 1-3 times per month Less than 1 time per month Does not test blood glucose level

Methods used to manage your diabetes?
Diet
Insulin pump
Pills/oral medication
Exercise
Insulin shots
Other
Shots other than Insulin

How many shots of insulin do you take per day?
Select Less than 1 per day 1 per day 2 per day 3+ or more per day I do not take insulin

How often, if ever, do you make adjustments to the amount of insulin you take?
Select Everyday Several times a week Once a week Once every 2 weeks Once a month or less often Never make adjustments

Yes, I would like to receive diabetes-related information and promotional offers from LifeScan, Inc. I agree that my information will be available to LifeScan, its affiliates and companies that work with LifeScan and that LifeScan may contact me for my opinions related to its business. (You can request that your information be removed from LifeScan’s contact list by calling 1-800-227-8862 or by emailing customerservice@LifeScan.com small.)

For more information about OneTouch® Products, visit www.OneTouchMeters.com.

Form last updated on August 20, 2008


AW 090-385 C

————————————————————————————————————————

About LifeScan | Privacy Policy | Legal Notice | Contact Us
The health information on this Web site is for general background purposes and is not a substitute for medical advice or treatment for specific conditions. Seek prompt medical attention for health care questions you have. Consult your physician before making changes to your medication, diet, fitness program, or blood glucose testing schedules.


No replies