Regime Submission Form

Regime Submission Form
...for probable use in an educational presentation.

To use this form you must be running Netscape 2.0 or higher, Internet Explorer 2.0 or higher, or AOL version 3.0 or higher!

Enter your Insulin information below by using both the pop-up menus and typing in blank fields.

Insulin Information Optional

Type Of Insulin Hour Of Injection (Noon = PM) Units in Injection Duration of one Injection in Hrs.

1

2

3

4

5

6

7

8

How sensitive are you to one EXTRA unit of insulin?:Optional!

Are you an Insulin pump user?

Enter your carbohydrate information below by using both the pop-up menus and typing in blank fields.

Carbohydrate Regime

Meal Hour of Meal (Noon = PM) Grams ( of Carbs)

1

2

3

4

5

6

7

8

How sensitive are you to extra Carbohydrates?:Optional!

Dawn Phenomenon?

IMPORTANT: Please describe your usual bG problem areas: How high do you go? and about when? How low do you go and about when? Also, what are your usual maximum readings?

Example: I have trouble with being in the low 60's in the early morning hours, and I am often near 240 an hour or two after dinner; however, I sometimes see readings (looking at a weeks worth of readings or so) as low as 45 and as high as 360.

Personal Information: Enter personal information below.

First Name

Last Name

Address Optional

City Optional

State Optional

Zip Optional

Email Address

I,(Type in your name), give DiabetesOnline and ITA Software, Inc. the right to publish my IDDM regime. I understand my name, address, and personal information will NOT be used unless I give my specific written permission

Carefully review your form before submitting it.

Insulin Information					Optional
	Type Of Insulin	Hour Of Injection	(Noon = PM)	Units in Injection	Duration of one Injection in Hrs.
1
2
3
4
5
6
7
8

Carbohydrate Regime
	Meal	Hour of Meal	(Noon = PM)	Grams ( of Carbs)
1
2
3
4
5
6
7
8

First Name
Last Name
Address		Optional
City		Optional
State		Optional
Zip		Optional
Email Address