Islet Cell Transplantation Interest Form

Name (First, Last)

Email address

Are you on any medications beside insulin for your diabetes? If yes, please specify medications used below.

Each month, approximately how many episodes of blood sugar below 55 mg/dL do you experience?

In the last 3 years, have you needed help from someone else to treat low blood sugar? If yes, how many times in the past 3 years?

Do you currently smoke cigarettes? If yes, for how many years? If yes, how many cigarettes a day?